Chronic Pain Management
Established Patient Follow Up Form
Name: _________________________________________ Date of Birth: ____________ Age: ______ Today’s Date: ____________
HEIGHT: ______________ WEIGHT: ________________ BP: _______________ PULSE: _________________
Reason for Today’s Visit (Mark ALL that apply)
Current PAIN Medications Prescribed by CBSI/Other Provider
Medication Name Dose Frequency Prescriber Provider
Routine Follow Up
Medication Problem or Change
Review Imaging
Post-Procedural Assessment
Medication Refill
New Problem: _________________
Review Test Result Other: _______________________
My CHIEF PAIN COMPLAINT is: (Mark only ONE)
headache
neck pain
left arm pain
Are your pain medications helping? Yes No
facial pain
mid-back pain right arm pain
-Improved Pain Relief: _______% (0-100%)
chest wall pain low-back pain left leg pain
-Functional Improvement: _______% (0-100%)
abdominal pain buttock pain right leg pain
groin pain
tailbone pain other: ____________
-Improved Quality of Life: _______% (0-100%)
My ADDITIONAL pain complaint(s) is (are): (Mark ALL that apply)
-Are there any side effects? Yes No
-If ‘Yes’, which?
headache
neck pain
left arm pain
Since your last visit, have you had pain injections? YesNo
facial pain
mid-back pain right arm pain
If ‘Yes’, which?
chest wall pain low-back pain left leg pain
If you had an injection, how much relief did it provide?
abdominal pain buttock pain right leg pain
_______% (0-100%)  N/A (I did not have a recent injection)
groin pain
tailbone pain other: ____________
Your pain right now:
____/10 constant
Your worst pain:
____/10 fluctuating, always present
Prescription medication or illegal drug misuse/abuse or
addiction:  Yes, currently  Yes, in the past  Never
Your least pain:
____/10 fluctuating, usually present
Your average pain:
____/10 fluctuating, rarely present
Are you receiving other treatments for your pain? Yes No
-Physical therapy: Helpful Not Helpful N/A
Indicate where your pain is located:
-Chiropractic: Helpful Not Helpful N/A
1. Use the following
-Massage/Acupuncture: Helpful Not Helpful N/A
letters to describe
-TENS Therapy: Helpful Not Helpful N/A
your pain.
-Bracing/Orthotics: Helpful Not Helpful N/A
Ache = A
-Other: __________________ Helpful Not Helpful N/A
Burning = B
Cramping = C
Since your last visit, any new testing/images? Yes No
Dull = D
If ‘Yes’, which?
Numbness = N
Since your last visit, any new medications? Yes No
Pins/Needles = P
If ‘Yes’, which?
Stabbing = S
Since your last visit, any changes in your health? Yes No
Throbbing = T
If ‘Yes’, which?
Muscle spasm = M
Since your last visit, any hospitalizations/surgery? YesNo
If ‘Yes’, explain?
2. Draw arrows
Since your last visit, any new blood thinners? Yes No
where the pain
If ‘Yes’, which?
radiates.
Since your last visit, other problems/concerns? Yes No
What makes your pain worse?
If ‘Yes’, which?
Review of Systems
Constitutional: Fatigue Fever Weight loss Weight gain
What makes your pain better?
Since your last visit at CBSI, has there been any new:
Balance problems
Numbness:  Arms  Legs
Difficulty walking
Tingling:  Arms  Legs
Bladder incontinence Weakness:  Arms  Legs
Bowel incontinence Other:__________________________
Since being treated at CBSI, how have the following changed:
Pain control Improved
Unchanged
Worse
Function
Improved
Unchanged
Worse
Quality of life Improved
Unchanged
Worse
Eyes: Blurring Double vision Vision loss Eye pain
ENT: Hearing loss Ringing Sinus Trouble Sore throat
Heart: Chest pain Ringing Irregular heartbeat Palpitations
Lungs: Short of breath Wheezing Cough Bloody sputum
GI: Abdominal pain Constipation Heartburn Bloody stools
GU: Bloody urine Painful urination Urinary Frequency
Urinary retention Impotence Urinary incontinence
MSK: Weakness Joint pain/swelling Muscle loss Spasms
Neuro: Headache Dizziness Weakness Seizure
Psych: Depressed Anxious Suicidal Homicidal
Colorado Brain and Spine Institute, Follow Up Intake Form, Revised 4/13/2015
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