Narcotic Medication Assessment Form
Instructions:		These questions must be carefully read and answered by the patient. This questionnaire should not be filled by anyone else other than the patient. If the patient is incapable of completing this form by themselves, family assistance is permitted, but the answers to the questions will still need to come from the patient.
Patientís Name: (Last, First, MI)				Telephone No.:		Date of Birth: (dd/mm/yy)
□ Yes	□ No		Item 1: Do you continue to have the chronic pain for which you were given your narcotic pain medications?
□ Yes	□ No		Item 2: Are your narcotic pain medications helping decrease your pain?
□ Yes	□ No		Item 3: Are you taking your medications as prescribed or directed by our pain physician?
□ Yes	□ No		Item 4: Are you and your family aware and understand that narcotic pain medications can be addictive and habit forming?
□ Yes	□ No		Item 5: Are you and your family aware and understand that these narcotic pain medications can cause death if taken inappropriately, if taken with alcohol, or if taken in combination or in addition to other narcotics, over-the-counter medications, or illegal drugs?
□ Yes	□ No		Item 6: Are you and your family aware and understand that the possible side-effects of these medications include, but are not limited to: allergic reactions (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives); slow, weak breathing; seizures; cold clammy skin; severe weakness or dizziness; unconsciousness; yellowing of the skin or eyes; unusual fatigue, bleeding, or bruising; constipation; dry mouth, nausea, vomiting, or decreased appetite; tiredness, or lightheadedness; muscle twitches; sweating; itching; decreased urination; or decreased sex drive?
□ Yes	□ No		Item 7: Are you and your family aware that everybody is different and that the same dose that provides you with pain relief may be sufficient to cause death to another human being, especially children?
□ Yes	□ No		Item 8: Have you received a copy of our ìPain Program Medication Policyî?
□ Yes	□ No		Item 9: Have you read the ìPain Program Medication Policyî?
□ Yes	□ No		Item 10: Do you have any questions about the ìPain Program Medication Policyî?
□ Yes	□ No		Item 11: Are you having any side-effects to your pain medication? (Nausea, vomiting, constipation, difficulty breathing, being too sleepy, lack of coordination, or mental impairment)
□ Yes	□ No		Item 12: Are you taking more medication than prescribed?
□ Yes	□ No		Item 13: Are you using, or have you used any illegal substances in the past month? (Marijuana, cocaine, heroine, amphetamines, PCP, etc.)
□ Yes	□ No		Item 14: Are you sharing your medications with anyone?
□ Yes	□ No		Item 15: Are you, your family, or anyone else selling your medications to anyone?
□ Yes	□ No		Item 16: Are you getting any pain medications or pain medication prescriptions from any other physician, dentist, or any other sources other than your pain physician at this office?
□ Yes	□ No		Item 17: Do you go to any other pain clinic(s)?
□ Yes	□ No		Item 18: Are you buying pain medications from the internet, other patients, street drug dealers, or any other sources, other than a licensed pharmacy?
□ Yes	□ No		Item 19: Are you or have you used more than one pharmacy in the past month?
□ Yes	□ No		Item 20: Do you have any other pain medication or pain medication prescription at home, other than what we have prescribed to last until the end of this month?
□ Yes	□ No		Item 21: Do you have any surplus narcotic pain medication left at home at the end of every month?
I certify that all of the above questions have been answered truthfully. I also understand that not answering truthfully constitutes an act of deception on my part and may result in my dismissal from this pain program.
					Patientís SignatureÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Date
					Healthcare Provider SignatureÝ -Ý Date