Today’s Date*
First Name*
Last Name*
Phone*
Email*
Insurance ID and Group number*
Address*
Date of Birth*
Age*
Referring Physician/How did you hear about us?*
Primary Care Physician*
Preferred Pharmacy*
Chief Complaint (Reason for your visit today)?*
Approximately when did this pain begin?*
What caused your current pain episode?*
How did your current pain episode begin?*
Suddenly Since your pain began how has it changed?*
Improved Worsened Stayed the same
Pain Description
Check all of the following that describe your pain:
Dull/Aching Cramping Squeezing Hot/Burning Numbness Tingling/Pins and Needles Shooting Spasming Tightness Stabbing/Sharp Throbbing None
When is your pain at its worst?
Mornings Daytime Evenings Middle of the Night Always the Same
How often does the pain occur?
Constant Changes in severity but always present Intermittent [comes and goes]
If pain "Choose One" is no pain and "10" is the worst pain you can imagine, how would you rate your pain?
Right Now:
The Best lt Gets:
The Worst It Gets: