Here are Your Chronic Pain Disease and Palliative Care Forms!

Do you suffer from a chronic pain disease? Is there no cure? Then you should fill out the Chronic Pain Disease and Palliative Care Certification Form. 

A while back I wrote about a trip I had taken to the Emergency Room. I was diagnosed with pneumonia and admitted to the hospital to receive IV antibiotics. I was treated with those antibiotics and Tylenol. My chronic pain was not addressed. I was in agony, not from pneumonia but from the chronic pain of fibromyalgia.

I was medicated in the emergency room for chest pain. Once I was moved into a hospital bed, there would be no further medication for the pain I was experiencing. My fibromyalgia went into a full flare due to a voluntary test I allowed them to run on me as a ‘teaching’ protocol.

Four doctors arrived in my room and asked to administer an ultrasound on my back to get pictures of my lungs. I agreed to let them do the ultrasound because I believed it would be a less invasive test and other patients may benefit from it. Bad decision. After allowing four doctors to deeply press the ultrasound device all over my back, the myofascia bruised and pain signals were activated throughout my body causing a very painful flare.

I told the admitting doctor that I would need to be treated for my chronic pain. I still didn’t realize the ultrasound had caused the flare at this point, all I knew was I was in a LOT of pain. She denied my request for pain medication, she refused to contact my primary doctor, and she stated I’d need to see a pain doctor on site. This pain doctor had left for the day and wouldn’t be returning until the next day after 5PM. It was 11AM…

The next 30 hours were unbearable… I still cannot talk about what I went through, and I cannot repeat the names I was called. It was terrifying and traumatic.

Never again. I will not ever let this happened again.

I found the Palliative Care Forms I was searching for! A man named Dr. Kline does so much for the chronic pain community. It was after listening to him I learned “Palliative Care,” and “Hospice” are two separate entities. Usually, when we think of hospice, we think of palliative care plans, but this need not be the case. Chronic pain patients are entitled to pain management. We are not drug seeking lunatics. We are not part of the so-called ‘opioid crisis!’ We are people who have an unusually high tolerance for pain medication because we are continually releasing pain-relieving substances our bodies naturally contain because our brain is merely responding to constant firing pain receptors.

Download and print out your Chronic Pain Disease and Palliative Care Certification Form. Your doctor, nurse practitioner, even your nurse can fill this form out, and you can keep a copy with you at all times!

I want to know how these forms work for you! If you have one of these already in place, please let me know if it has been useful! We may have more work to do, but this could be a step in the right direction!


26 thoughts on “Here are Your Chronic Pain Disease and Palliative Care Forms!

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  1. What a horrifying experience for you… for any of us with chronic pain issues!

    I had no idea that there was such a form. Long ago I stopped going to the ER or into the hospital for anything other than a life threatening emergency because the pain is NEVER addressed and it’s not worth the everything else getting worse unless it will kill me.

    I’m… Amazed that such a form exists! All these years…

    Thank you for sharing, Kim. Thank you for sharing this form with us!


    Liked by 2 people

    1. I completely know where you are oming from… this just can’t be handled the way it has been. We shouldn’t be afraid to seek medical attention! EVER. And we all have a right to pain management. Get these forms filled out and please report back! I want to know these forms work for everyone! Wishing you the best Kit!

      Liked by 1 person

    1. Still fighting the pneumonia AT HOME… but I feel much better after having found these forms. I am finally overcoming the trauma. Thank you Bojana. I need to get back to reading blogs as well as keeping my own going. I won’t lie. I was in a very fragile state for quite awhile. It was a very uncomfortable solitary feeling. No more! xo

      Liked by 2 people

  2. Thank you for finding this and sharing your experience, I know it has been horrific, I can’t imagine the trauma this has left you with. They have caused you to have PTSD, that’s unforgivable. Although I have pain all the time I do not take medication for it regularly. Not that I wouldn’t if I could. (I do use cannabis, but it doesn’t take the pain all away, and if I were in the hospital I couldn’t use it. It was horrible when I had my hip replaced and I couldn’t take pain meds. I was able to take them for one day, then the itching go way too bad. I took Tylenol and cannabit, that is the only things that worked for me. Not only do opioids make me itch like crazy most aren’t that effective on me.
    I cannot imagine the what you went through. I do not understand why they would not give you what your PCP prescribed for you, that should be illegal. All of what happened to you should be illegal. It simply is not right.

    An interesting thing…
    I had gene testing done this month and just got the results today. It shows that I metabolize many medications way too fast for them to do any good, and some I have a “gene drug interaction”, this includes most opioids.
    But it also gives me a list of medications that I could try that could help with pain. I think that’s awesome.
    I got the testing done to find out which psychiatric drugs would be most helpful for me, I’m eager to see how this all plays out.
    I wish everyone could do this. The wonders of it, Medicare paid for it 100%!
    I was going to attach the page about pain meds for you to see, but I don’t know how.
    if you are interested let me know and I’ll send it to you.

    I’m very proud of you my friend. You have been so very strong through all of this.
    Love and light.

    Liked by 1 person

    1. It was horrific. But now I have a solution. I will have my forms filled out and with me at all times. I will not live in fear any longer! NO MORE FEAR.

      I am definitely interested in seeing the list of pain meds. Infact, I believe you could attach what medications you can take for pain to the Chronic Pain Disease and Palliative Care Form! Can you email me the page and the name of the test? OR mail a copy to me? AS much info as you have, and if Medicare pays for it, we should make it available in a blog. I can write one up if you’d like me to. There are many that cannot take pain relievers, and this would be great information for them to have. The name of the test, Medicare coverage, and a list of alternative medications.

      If you want me to do a blog on it send me, everything you can, and I’ll cover it. You have my home address? If not email me and I’ll email you back.

      This is terrific information Wen. Absolutely brilliant to hear this exists!!! xoKim


    1. Thanks for sharing these forms! I hope it becomes so common an admitting physician will simply ask if you have the Chronic Pain Disease and Palliative Care Form! Wouldn’t that be wonderful!

      I am healing mentally and physically. Just taking a little longer than expected. I appreciate your concern, my friend! ~Kim xoxo

      Liked by 1 person

    1. Thank you. I know that many doctors are really in a bad spot with all the restrictions placed on them. I hope these forms will help them administer appropriate pain management. Yes, I volunteered to participate never expecting the outcome I had. Today has been a good day. Thanks so much!

      Liked by 1 person

    1. I am so sorry to hear this. There will be a huge paradigm shift, from NO access to medication with people probably dying… suicide rates will increase before some medical personnel will react. Keep trying! Try to get to a pain clinic doctor in the interim. You will get through this… always ask for a patient advocate if you are hospitalized. Remember it’s in the Patient Bill of Rights to be treated for pain when hospitalized (sometimes it helps to remind staff of this). This is a brand new form! It is in response to the trending “opioid crisis.” Palliative care has been status quo for a long time, adding chronic pain disease is very new! Look at it as one approach, but there are many ways to handle your pain even if a doctor is not comfortable filling one of these out. Truthfully, not many are… mine did not, but took the copies I gave her to review and share with her colleagues. It is a process!!! Hang in there and please keep trying, remembering alternatives to assist you with pain. Stay in touch. ~k.


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