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Pain Assessment Intake
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First Name
Last Name
Email
Phone/Mobile
Date of Birth (DD/MM/YYYY)
What is your main pain problem?
Where is your pain?
How long have you had it?
– Select –
Less than 6 weeks
6 weeks – 3 months
3 months – 1 year
More than 1 year
How did it start?
What is its impact on you?
How severe is it? (0-10)
0
What investigations have you had?
XRays
CT scans
MRI scans
Blood tests
DEXA scan
What treatments have you had?
Physiotherapy
Medications
Acupuncture
TENS
Pain injections
Radiofrequency Ablation
Surgery
What are your current pain medications?
Do you have any allergies?
Any relevant past medical history?
Do you currently have any “Red Flag” Symptoms?
New weakness
Numbness in saddle area
Loss of bladder/bowel control
Unexplained weight loss
Fever
Recent trauma
Cancer diagnosis
None of the above
Funding Source
Self Pay
Private Medical Insurance
Insurer
Membership Number
Approval code
I understand that this form is not an emergency medical service and is intended for non-urgent outpatient enquiries only.
I agree
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