1. Personal & Health Information

Name: Age: Contact Information: Primary Provider Name & Contact: Current Pain Management Regimen: Typical Pain Level (1-10): Known Pain Triggers and Patterns:

Recommendation: If you have a complex regimen, create a detailed medication log and list daily therapies to share with any travel healthcare provider. TBL Action: Use the Ticked Bucket List digital tool to compile and securely store your pain management details and share them with both your primary and travel care teams.

2. Pre-Travel Health Assessment

Pain Management Objectives for This Trip: Recent Changes in Your Pain or Symptoms: Potential Travel Triggers:

Long Flights Time Zone Changes Unfamiliar Environments

Rate Your Concern for High-Risk Triggers (Low, Medium, High):

Recommendation: If you report worsening symptoms or new issues, consider a pre-travel consultation. For high-risk triggers, develop specific strategies like extra rest or supportive devices. TBL Action: Use our online assessment tool to evaluate your status and access tailored risk management strategies via the Ticked Bucket List portal.

3. Itinerary & Activity Customization

Have you scheduled regular rest breaks?

Yes No

Are you choosing accommodations with accessible and comfortable facilities?

Yes No

Do your planned activities allow flexibility if you need to adjust for pain or fatigue?

Yes No

On a scale from 1–10, how well does your itinerary support your pain management needs? What modifications can you make to improve comfort during travel?

Recommendation: If your itinerary rating is below 7, consider adding more downtime and reducing strenuous activities. TBL Action: Consult with our travel concierge via the Ticked Bucket List app to adjust your schedule for enhanced comfort and flexibility.

4. Medication & Documentation Management

List All Required Medications (with dosages and timing): Do you have an extra supply for unexpected delays?

Yes No

Have you adjusted your medication schedule for time zone differences?

Yes No

Do you have current prescriptions and a recent medical summary?

Yes No

Do you have a letter from your healthcare provider detailing your pain management plan?

Yes No

Are your medical records and emergency contacts easily accessible (digitally or in hard copy)?

Yes No

Have you packed additional pain management supplies (e.g., heat packs, portable TENS unit, relaxation aids)?

Yes No

Recommendation: If you lack an extra supply or haven't adjusted your schedule, contact your provider for additional prescriptions and guidance. TBL Action: Use our medication scheduling tools and digital repository via the Ticked Bucket List app to manage your supplies and documents effectively.

5. Coordination with Healthcare Providers

Have you arranged a method to contact your primary pain management provider during travel?

Yes No

Provider's Preferred Contact Method and Available Hours: Have you given consent for sharing your health details with travel care or local providers?

Yes No

How often do you plan to check in with your primary provider while traveling?

Recommendation: If you haven't set up telemedicine, do so before departure. TBL Action: Use our integrated telemedicine platform and digital consent forms via the Ticked Bucket List app to streamline communication and data sharing.

6. Telemedicine & Local Healthcare Integration

Is your telemedicine app or service set up and tested?

Yes No

Have you identified local pain management clinics or hospitals at your destination?

Yes No

Local Providers or Emergency Health Contacts (if any):

Recommendation: If not set up, test your telemedicine service now. TBL Action: Use our support guides and browse our vetted local provider list available on the Ticked Bucket List platform for seamless integration.

7. Crisis & Emergency Action Plan

Do you have a detailed plan for a pain flare-up or emergency?

Yes No

Local Emergency Numbers and Nearest Medical Facility: Outline steps to take if your pain intensifies unexpectedly:

Recommendation: If you haven't prepared an action plan, create one now including steps for contacting local services and your provider. TBL Action: Download our emergency action plan template from the Ticked Bucket List website for quick integration.

8. Mind-Body Integration & Self-Care Strategies

What relaxation or mind-body techniques do you regularly practice? Apps, Guides, or Tools for Managing Stress and Pain: Daily Self-Care Routine (e.g., morning meditation, breaks, evening wind-down):

Recommendation: Incorporate even brief mind-body practices daily. TBL Action: Access our curated list of practices and video tutorials on the Ticked Bucket List app for guidance.

9. Post-Travel Evaluation & Improvement

What aspects of your pain management plan worked well during travel? What difficulties did you encounter and how can you adjust your plan for future trips? Post-Travel Follow-Up with Your Primary Provider:

Recommendation: Reflect on successes and challenges. TBL Action: Complete our post-travel feedback form and schedule a review via the Ticked Bucket List app.

Usual Pain Management Care to Travel Pain Management Integration Tool

1. Personal & Health Information

2. Pre-Travel Health Assessment

3. Itinerary & Activity Customization

4. Medication & Documentation Management

5. Coordination with Healthcare Providers

6. Telemedicine & Local Healthcare Integration

7. Crisis & Emergency Action Plan

8. Mind-Body Integration & Self-Care Strategies

9. Post-Travel Evaluation & Improvement