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0141-429-0943
36 Admiral Street, Kinning Park, G41 1HU
ggc.gp52260@nhs.scot
Mull Medical Practice
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Register as a New Patient
Self Referral
Useful Contacts
Forms Library
Self Service Hub
Chronic Pain & Painkillers Review
Please complete this form before your next prescription request.
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" indicates required fields
Name
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First
Last
Email
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Date
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DD slash MM slash YYYY
Phone Number
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Please name the medication and dose we have requested for review.
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How regularly do you take the medication you highlighted in the previous question ( once or several times a day etc) and for how long (months / years)?
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Where is the pain located on your body?
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Please describe in your own words, what the pain is like. (sharp, dull, constant, intermittent)
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Please rate pain that you experience on a scale of 1-10 BEFORE taking this medication. (with 1 being very low pain and 10 being extreme )
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1
2
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5
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7
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10
Please rate the overall pain that you experience on a scale of 1-10 after taking this medication ( 1 being very mild pain and 10 being extreme pain)
1
2
3
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5
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9
10
How long does the pain relief last for? (hours/min)
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Please describe any triggers you have found that brings on the pain or makes it worse.
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Please describe anything other than medication that helps to relieve the pain?
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Please describe any side effects of taking the pain medication. ( if none , please simply state this )
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Please describe in your own words, how the pain limits your day-to-day activities? ( eg does it stop you from working, walking , lifting etc . If it doesn't limit you, please simply state this)
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Please list any other painkillers you are taking, either regularly or as required (e.g. paracetamol).
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Please let us know if you have any questions or concerns about the medication that you take. (if none, you can leave this section blank)
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If you feel your medication is not providing adequate relief, experiencing significant side-effects or you wish to discuss anything about your pain management further, please don't hesitate to make an appointment with a clinician. By providing this information, it helps us to understand your current pain issue and how it is being managed . In some cases, we may arrange further contact or request to make an appointment to discuss your pain management further
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I have understood the above.