Patient Name:
Gender
Male
Female
Date of Birth
Height
Weight
Please list any/all allergies:
What is the main problem for which you are seeking treatment?
Was there an event that caused your current pain? (Please be very specific)
Are there factors that make your pain...
Better? (please list)
Worse? (please list)
Please rate your pain intensity on a scale from 0 = no pain to 10 = excruciating, incapacitating worst pain possible.
Your pain at its worst in the past month or since your injury
Your pain at its least in the past month or since your injury
Your current pain
How often do you have your pain?
Constantly (100% of the time)
Nearly constantly (60% to 95% of the time)
Intermittently (30% to 60% of the time)
Occasionally (less than 30% of the time)
Please indicate the location of your pain in the picture below:
Eye
Front of Neck
Shoulders
Chest
Upper Arms
Lower Arms
Hand
Wrist
Front Thigh
Fingers
Legs
Feet
Back of Head
Back of Neck
Upper Back
Mid back
Lower Back
Belly
Hips
Buttocks
Back Thigh
Calves
Bottoms of Feet
Please list all medications and/or supplements you are currently taking:
Practitioner's Name
Practitioner's Clinic
Practitioner's Phone Number
Pain ASsessment
Do any of the following apply to how your pain feels?
Stabbing
Burning
Tingling
Aching
Itching
Squeezing
Shock-like
Shooting
Other
If you selected other, please describe:
Front of Head
Please check all the treatments you have tried or are currently using for your pain:
Physical Therapy
Accupuncture
Massage Therapy
TENS Unit
Chiropractor
Surgery
Spinal Cord Stimulator
Cognitive Behavior Therapy
Other
Biofeedback
Hypnosis
Nerve Block
Trigger Point Injections
Rehabilitation
Radio Frequency Lesioning
Nutritional Supplements
Dietary Changes
If you selected "other", please describe:
Phone
Address (City, State, Zip)
Email Address Text Field Label
Would you like to receive emails from our pharmacy regarding events & seminars we host? You will also receive pharmacy promotions?
(Your email is never shared outside our pharmacy.)
Yes
No