Postoperative Opioid Monitoring Form
Monitor recovery and opioid use following surgery. Please complete all relevant sections to assist in patient care.
Patient Full Name
*
First Name
Last Name
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery
*
Opioid Medication Used
*
Please Select
Oxycodone
Hydrocodone
Morphine
Tramadol
Other
Current Pain Level (0 = no pain, 10 = worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Have you experienced any of the following side effects?
*
Nausea
Drowsiness
Constipation
Itching
None
Bowel Activity Status
*
Normal
Reduced
No bowel movement >48h
Have you experienced any alert symptoms?
*
Difficulty breathing
Severe drowsiness/unresponsiveness
Confusion
None of the above
Does the patient need follow-up or further medical review?
*
Yes
No
Unsure
Submit Monitoring Form
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