Pain Management Patient Record Form
Please complete this form with your pain history, current symptoms, treatments, and related medical information so your care team can document and review your pain-management needs.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex / Gender
*
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Pain History and Current Symptoms
Primary Pain Location / Body Area
*
Pain Onset Date or Duration
Pain Type / Description
*
Pain Intensity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Pain Frequency
*
Constant
Daily
Intermittent
Occasional
Other
Pain Pattern / Timing
Morning
Afternoon
Evening
Night
After Activity
Unpredictable
Other
Triggers, Relief, and Functional Impact
Pain triggers
*
Movement
Prolonged sitting or standing
Stress or anxiety
Cold weather
Heat
Certain foods or drinks
Physical exertion
Lack of sleep
Other
What helps relieve your pain?
*
Rest
Heat therapy
Cold therapy
Stretching
Exercise or physical therapy
Massage
Medication
Relaxation techniques
Changing position
Other
How does pain limit your daily activities?
How does pain affect your sleep?
No impact
Mildly disturbed
Moderately disturbed
Severely disturbed
How does pain affect your mobility or physical activity?
No impact
Mild limitation
Moderate limitation
Severe limitation
Current Treatments and Medical Background
Current Pain Medications
Other Therapies Tried
Physical therapy
Heat/Ice
Injections
Exercise
Counseling
Massage
Chiropractic care
Acupuncture
Other
Medication Allergies or Adverse Reactions
Relevant Medical History or Conditions Related to Pain
Current Clinician Notes or Prior Diagnoses
Submit Record
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