Questionnaires


 

Pain Questionnaire & WHO-5

Click to download. This is our standard questionnaire to monitor overall progress in pain management and overall well-being. Scores fluctuate over time but we are looking for progress not perfection!


Attention Deficit Disorder Questionnaire

Click to download. This questionnaire allows us to recognize and monitor signs and symptoms of Attention Deficit Disorder


Urine Drug Screen RX

Click to download. This is our standard prescription for a urine drug screen. Once downloaded and printed out please complete with date, your name, and your date of birth. Most laboratories will then honor the lab requisition. Call office if problems.


New Patient forms

Above click to link to forms we often use at the start and intermittently in the course of care.


AGREEMENTS AND CONSENT FORMS

The following two forms
OMS Controlled Substance Use Agreement
General Opiate/Opioid Information Sheet & Consent
are the agreements/consents related to the use of prescribed controlled substances. If you are considering having us prescribe you any controlled substance, please review and be prepared to annually sign the agreement . If you are wanting to be prescribed an opioid such as buprenorphine, morphine, oxycodone, tramadol, etc. please also review and be prepared to sign annually the opioid use agreement:

Location
J. Kimber Rotchford, MD
1136 Water Street, Suite 107
Port Townsend, WA 98368
Phone: 360-385-4843
Office Hours

Get in touch

360-385-4843