• Welcome!

    Thank you for filling this Intake Form. The questions here are standard for most pain clinics in Australia.

    I really appreciate the time and effort in filling these forms. They will absolutely assist me in understanding your needs.

  • Who is filling this Intake Form?*
  • Title*
  • Date of Birth*
     - -
  • Sex- Sex assigned at birth*
  • Gender- Self-identified*
  • Preferred pronouns*
  •  -
  • What is your contact preference?*
  • Do you require an interpreter?*
  • Marital Status*
  • Are you of Aboriginal or Torres Strait Islander Origin?

  • Health Insurance Information

  • Have you ever served in the Australian Defence Force? Are you a client of the Department of Veterans' Affairs or have you received a benefit or support from the Department of Veterans' Affairs?*
  • Is there a compensation case relating to this episode?*
  • If yes, is this compensation case relating to this episode*

  • Please include your health providers

    This will assist in providing correspondence

  • Pain details

  • How did your main pain begin?*

  • Please indicate on body chart:        


     Stabbing

    Aching

     Throbbing

    Tingling

     Numbness

     Burning

  • Pain Level on Scale 0-10 (0 = no pain):

  • Are your symptoms:*
  • What does the pain feel like?*
  • Are you taking opioid medications during the week?*

  • Part 2

  • Do you have periods during the day when you have temporary episodes of uncontrolled pain?*
  • What does the pain feel like?
  • Do you know what causes these breakthrough pain episodes?
  • Is the breakthrough pain the same type of pain as your usual pain?
  • Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?
  • To what extent does avoiding activities due to fear of an episode of breakthroughpain compromise your quality of life?
  • How satisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain?

  • Investigations and Past treatments

    Please fill this to the best of your knowledge. It is very important that all test results and/or scans be available in your appointment. I have access to some, but not all pathology or imaging providers. So please bring originals or copies of results.
  • Rows
  • Rows

  • My Goals and expectations

    This section is OPTIONAL
  • I need help to

  • Other conditions

  • Do you have a mental health condition?
  • Do you identify or have had diagnosis of a neurodiverse condition or expression?
  • Do you have a muscle, bone or joint problem
  • Do you have a heart or circulation problem (even if well managed/treated)
  • Do you have digestive problems
  • Do you have a respiratory problem
  • Do you have a neurological problem

  • Occupation section

    This section allows Dr Kodsi to understand your circumstances better

  • Medication use

  • Rows
  • Do you have any allergies*

  • Brief Pain Inventory

  • Description of pain:

    Please rate your pain but checking the one number that best describes the following:
  •

  • Description of function:

    During the last 7 days, how much has pain interfered with the following
  •

  • Overall Impression

  • 11. Fill in the oval next to the one number that best describes your overall quality of life over the last 7 days.

  • Depression, Anxiety, Stress, Scale (DASS - 21)

  • Dass 21

    Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you "over the past week".  There are no right or wrong answers.  Do not spend too much time on any statement.

    The rating scale is as follows:

    0  Did not apply to me at all

    1  Applied to me to some degree, or some of the time

    2  Applied to me to a considerable degree, or a good part of time

    3  Applied to me very much, or most of the time
  • (1) I found it hard to wind down*
  • (2) I was aware of dryness of my mouth*
  • (3) I couldn't seem to experience any positive feeling at all*
  • (4) I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)*
  • (5) I found it difficult to work up the initiative to do things*
  • (6) I tended to over-react to situations*
  • (7) I experienced trembling (eg, in the hands)*
  • (8) I felt that I was using a lot of nervous energy*
  • (9) I was worried about situations in which I might panic and make a fool of myself*
  • (10) I felt that I had nothing to look forward to*
  • (11) I found myself getting agitated*
  • (12) I found it difficult to relax*
  • (13) I felt down-hearted and blue*
  • (14) I was intolerant of anything that kept me from getting on with what I was doing*
  • (15) I felt I was close to panic*
  • (16) I was unable to become enthusiastic about anything*
  • (17) I felt I wasn't worth much as a person*
  • (18) I felt that I was rather touchy*
  • (19) I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)*
  • (20) I felt scared without any good reason*
  • (21) I felt that life was meaningless*

  • PC-PTSD

  • Directions

    Think back over your entire life, have you ever had an experience that was so frightening, horrible, or upsetting that IN THE PAST MONTH you:

  • Pain Catastrophising Scale

    We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

  • When I am in pain…….

  • I worry all the time about whether the pain will end*
  • I feel I can’t go on.*
  • It’s terrible and I think it’s never going to get any better*
  • It’s awful and I feel that it overwhelms me.*
  • I feel I can’t stand it anymore*
  • I become afraid that the pain will get worse.*
  • I keep thinking of other painful events*
  • I anxiously want the pain to go away*
  • I can’t seem to keep it out of my mind*
  • I keep thinking about how much it hurts.*
  • I keep thinking about how badly I want the pain to stop*
  • There’s nothing I can do to reduce the intensity of the pain*
  • I wonder whether something serious may happen.*

  • Acknowledgements We acknowledge use of the following questions and assessment tools: Pain Chart: Childhood Arthritis and Rheumatology Research Alliance, www.carragroup.org von Baeyer CL et al, Pain Management, 2011;1(1):61-68 Modified Brief Pain Inventory questions, reproduced with acknowledgement of the Pain Research Group, the University of Texas MD Anderson Cancer Centre Depression, Anxiety and Stress Scale, Lovibond SH & Lovibond PF (1995) Pain Self-Efficacy Questionnaire, Nicholas MK (1989) Pain Catastrophising Scale, Sullivan MJL (1995) Work productivity questions from the Work Productivity and Activity Impairment Questionnaire, Reilly MC, Zbrozek AS & Dukes EM (1993)

  • Consent- Mandatory

    To provide the best care, we require consent to the following prior to providing you an appointment.

  • Dr Antony (Tony) Kodsi is a private pain specialist clinic.

    This means that you will be required to make full payment for your appointment. You will be able to receive a partial rebate from Medicare after that.  

    Please note: to receive a rebate from Medicare, you will need a letter of referral from your GP or Specialist prior to your first appointment. Obtaining a rebate is your responsibility- but we are more than happy to assist! See more about this in our Payment Policy.

    1. WorkCover and TAC patients are required to pay for their first visit, with the possibility of review being billed to the insurer dependent upon approval.
    2. DVA Gold Card holders’ accounts are sent directly to the Department of Veterans Affairs, and we ask that White Card holders please discuss their coverage prior to attending to assess whether they will be covered for the cost of their visit.

    I am highly trained and qualified, and strive to deliver an excellent quality of care and service to all my patients and their families; my consultation fees are set at AMA recommended rate and benchmarked to others with the same service.

  • Consent- Optional

    To provide the best care, we require consent to the following prior to providing you an appointment.

  • Your rights

  • Welcome to our pain clinic. We are committed to delivering respectful, safe, and high-quality care. Here are your rights as a patient:


    1. 🧍‍♂️ Be Treated with Dignity and Respect
    You have the right to be treated with kindness, respect, and without discrimination—regardless of your age, gender, background, or beliefs.
    Your privacy and cultural needs will always be considered in your care.

    2. 💬 Clear and Honest Communication
    You have the right to clear, honest, and understandable information about your health condition, treatment options, and any proposed procedures.
    We will answer your questions in a way you understand and take the time to ensure you feel heard.

    3. 🩺 Informed Decision-Making
    You have the right to be involved in decisions about your care.
    We will explain the risks, benefits, and alternatives before you consent to any procedure or treatment.
    You can refuse or stop treatment at any time (where safe and lawful).

    4. 🤝 Respect for Your Autonomy
    You can bring a support person with you to your appointment.
    You may seek a second opinion or ask for a referral to another specialist.
    You have the right to access your health records upon request.

    5. 🔒 Privacy and Confidentiality
    Your personal and health information is kept private and only shared with your consent or where legally required.
    We follow strict policies to protect your data and respect your confidentiality.

    6. 💡 Feedback and Concerns
    You are encouraged to give feedback or raise concerns without it affecting your care.
    If you are unhappy, we will listen respectfully and work to resolve the issue promptly.
    You can also escalate concerns to the NSW Health Care Complaints Commission if needed.

    7. 🧑‍⚕️ Safe and High-Quality Care
    You have the right to receive safe, evidence-based care delivered by qualified professionals.
    We aim to ensure continuity of care, especially for complex or long-term pain issues.

    Need Help Understanding Something?
    We are here to support you. Please don’t hesitate to:

    Ask us to repeat or explain something again.
    Request written information or interpreters if needed.
    Let us know how we can make you more comfortable.

  • Your responsibilities

  • 🗓 Appointments and Cancellations
    We will send you a confirmation text in the week leading up to your appointment.

    If you are unable to attend, please let us know as early as possible. This helps us offer the appointment to another patient who may be in urgent need. Missed or late cancellations can have a significant impact on others waiting for care.

    A cancellation fee may apply if appointments are missed or cancelled with insufficient notice, in line with the Inner West Pain Centre’s policy.


    💬 Respectful Behaviour
    We are committed to providing a safe, welcoming, and professional environment for all our patients and visitors.

    Our team will always treat you with respect, kindness, and compassion—and we ask that this be returned.
    We understand that living with pain can be distressing, but we cannot tolerate:

    Aggressive language or behaviour
    Threatening, rude, or abusive conduct
    Inappropriate written or verbal communication
    Such behaviour may result in refusal of further appointments or referral to another service.


    🧍‍♂️ Patient Responsibilities
    As a patient of our clinic, we ask that you:

    Attend appointments on time, or give sufficient notice if you need to cancel or reschedule
    Treat staff and other patients with respect, courtesy, and understanding
    Provide accurate and complete information about your health, medications, and treatments
    Follow agreed treatment plans where possible, and raise concerns if you're unsure
    Let us know if you have any changes in your health, medication, or contact details
    Ask questions if anything is unclear—we’re here to help
    We believe that working together with mutual trust and respect helps us provide you with the best possible care.


    ⚖️ Medicolegal Requests
    Our clinic is here to support you with your pain management and improve your quality of life.

    We do not provide consultations for the sole purpose of medicolegal or legal claims.
    However, if a report is requested by your insurer or legal representative as part of your care, we may be able to prepare this upon request. Please speak to our team for more information about the process and any applicable fees.

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