Pain Management Intake

PATIENT INFORMATION

Full Name

DOB

Phone

Email

Insurance

PAIN HISTORY

Primary pain complaint

When did pain start?

Injury

Yes

No

Pain scale

PAIN LOCATION

Pain location

Body diagram

PREVIOUS TREATMENTS

IMAGING AND TESTS

Single choice

MRI

X-ray

Date

CURRENT PAIN MEDICATIONS

Medication / Dose / How Often

FUNCTIONAL LIMITATION (HOW HAS PAIN AFFECTED YOU? 0 = NOT AFFECTED, 10 = COMPLETELY AFFECTED)

Daily activities

Walking/standing

Sitting

Work/occupation

Sleep

Mood

Relationships

Household tasks

Driving

Exercise

OPIOID / RISK SCREENING

Family history of substance abuse

Yes

No

Personal history of substance abuse

Yes

No

Age 16-45

Yes

No

History of preadolescent substance abuse

Yes

No

psychiatric treatment: ADD/OCD/bipolar/schizophrenia

Yes

No

Psychiatric diagnosis and medication

UPLOAD DOCUMENTS

Insurance Card

Photo ID

MRI / X-Ray Reports

Previous Pain Records

CONSENT AND SIGNATURE

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Date

Month

Day

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NM

N.M Wellness

IN FAMILY HEALTH

212-347-5887

37 East 30th Street
New York NY 10016

Fax: 702-974-8629

NEW PATIENTS · Pain Management