CHRONIC PAIN MANAGEMENT AGREEMENTPain Management Agreement • April 22nd, 2016
Contract Type FiledApril 22nd, 2016PAIN MANAGEMENT TREATMENT PLAN Treatment Indication: Physical Goals: Educational Goals: Mental Health Goals: CD Program Goals: Measurable Objectives: Manage ADLs: Activity log: Engage in programming/work: Engage in exercise/hobbies: Exercise log: Utilization of healthcare resources: Pain intensity/physical activity scores: Compliance with prescriptions: Compliance with other treatments (heat, ice, stretching, strengthening, use of DME, physical therapy regime): Third-party observations: Urinalysis: Planned Diagnostics: Drugs/Dose: Next visit: First Quarterly Visit: Exacerbation Mgmt: