EMERGENCY TREATMENT INFORMATION:
I
am experiencing
extreme pain resulting from my Chronic Pain condition(s). With this
form is a letter,
verifying
my diagnosis and treatment by my doctor presently.
REGISTRATION INFORMATION:
_____________________________________________________________________________
Full
Name
_____________________________________________________________________________
Address City State Zip
Code
_____________________________________________________________________________
Home Phone
Office Phone
_____________________________________________________________________________
Employer
_____________________________________________________________________________
Emergency Contact
Relationship Phone Number
TREATMENT INFORMATION:
On a scale of
1-10, currently my pain is ________.
To treat this pain that my condition(s)
causes me, the following medications have been used:
______________________________________________________________________________
Medication/
Dosage/ Time Taken/
______________________________________________________________________________
Medication/
Dosage/ Time Taken/
______________________________________________________________________________
Medication/
Dosage/ Time Taken/
OTHER MEDICATIONS:
______________________________________________________________________________
Medication
Dosage Time Taken
______________________________________________________________________________
Medication
Dosage Time Taken
_____________________________________________________________________________
Medication
Dosage Time Taken
KNOWN
ALLERGIES:
_______________________________________________________________
______________________________________________________________________________
Signature
Date
This form
provided by Our Chronic Pain Mission
http://cpmission.com/
� 2002
OCPM