Chronic Pain and Painkillers Review Form

This form is for us to assess how you are managing on your chronic pain medication, and whether it is working for you.

The long term use of painkillers can have a reduced effect on some medical conditions (e.g. fibromyalgia) and the painkillers can lose their effectiveness or even stop working for the condition.

Long term use of painkillers can also result in dependency on the medication.

For most conditions there may be other treatment options. Patients do find the website Live Well With Pain to be useful.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

Home Address

Postcode

Best telephone number to contact you

One of the clinicians will call you on the number provided in the next couple of weeks

Review Questions

What are you taking the painkillers for?

Which clinic first prescribed you this medication?

Do you feel that the medication is helping?

Could you be dependent on this medication?

Do you want to reduce or stop this medication?

Provide any comments for the clinician here

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Ongar Health Centre • Ongar War Memorial Medical, Fyfield Road, Ongar, Essex, CM5 0AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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