SOAAP_24

Laden...

Patient Qs
This information will let us know more about you.

PERSONAL INFORMATION

Patient’s Name: *

Date of birth: *

Male

Sex

Female

SOAPP® Version 1.0 - SF

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.

Please answer the questions below using the following scale: 0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often

How often do you have mood swings? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you felt a need for higher doses of medication to treat your pain? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you felt impatient with your doctors? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you felt that things are just too overwhelming that you can't handle them? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often is there tension in the home? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you counted pain pills to see how many are remaining? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you been concerned that people will judge you for taking pain medication? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often do you feel bored? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you taken more pain medication than you were supposed to? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you worried about being left alone? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you felt a craving for medication? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have others expressed concern over your use of medication? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have any of your close friends had a problem with alcohol or drugs? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have others told you that you had a bad temper? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you felt consumed by the need to get pain medication? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you run out of pain medication early? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have others kept you from getting what you deserve? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often, in your lifetime, have you had legal problems or been arrested? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you attended an AA or NA meeting? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you been in an argument that was so out of control that someone got hurt? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you been sexually abused? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have others suggested that you have a drug or alcohol problem? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you had to borrow pain medications from your family or friends? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

How often have you been treated for an alcohol or drug problem? *

0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often

Total Score

Please include any additional information you wish about the above answers. Thank you.

(949) 441- 5445 (949) 441- 5450 info@abovepain.com
16405 Sand Canyon Ave, suite #210 Irvine, CA 92618
5750 Downey Ave., suite #201, Lakewood, CA 90712

Mission Advanced Pain Management & Spine Center
offers a variety of the most Advanced, evidence-based treatment modalities that are customized to treat your specific condition.

Patient Qs This information will let us know more about you.

PERSONAL INFORMATION

Male

Sex

Female

SOAPP® Version 1.0 - SF

Patient Qs
This information will let us know more about you.