Pain Management Intake Form

The Pain Management Intake Form is specifically designed for pain medicine practices, capturing the detailed pain history and functional assessment that pain specialists need for comprehensive evaluation and treatment planning. This template collects patient demographics alongside a thorough pain assessment covering location (body diagram), character (sharp, dull, burning, aching, shooting), intensity (numeric rating scale 0-10 for current, best, worst, and average pain), duration, onset, temporal pattern, aggravating and alleviating factors, and radiation pattern. The functional impact section documents how pain affects sleep, work, daily activities, mood, and relationships.

Built for interventional pain management, chronic pain, spine care, and multidisciplinary pain clinics, this form includes sections for prior pain treatments (physical therapy, chiropractic care, acupuncture, injections, nerve blocks, spinal cord stimulation, intrathecal pumps), imaging review (MRI, CT, X-ray, EMG/NCS), current pain medications with dosages and effectiveness, opioid risk assessment (aligned with ORT screening), and prior surgical history relevant to pain. The psychological screening section captures depression and anxiety symptoms, catastrophizing patterns, and prior behavioral pain management.

All fields are HIPAA-compliant and structured for the pain management workflow. The comprehensive pre-visit documentation allows pain specialists to review the full pain history, identify patterns, evaluate prior treatment response, and develop an individualized treatment plan. The opioid risk screening and medication documentation support safe prescribing practices and compliance with state prescription drug monitoring requirements.