Partners Against Pain: Integrated Pain
Chronic Pain Clinic
REVISED Aug 17 ‘11
PATIENT HISTORY FORM
Page 1 of 4
Patient Identification
Allergies: _____________________________
Gender □ Male □ Female □ Language _____________ □ Age _____
Insurance Coverage
Yes
No Name of Insurance Company ___________________________
A. PAIN HISTORY: You may have been sent to our services after you have been diagnosed with a
certain condition or because you have persistent pain. If you have received a diagnosis, please
tell us about that or describe your pain in your own words:
Diagnosis: ____________________ Other Specialists or Investigations: ___________________

When and how did the pain start? If possible, provide month and year.

What improves your pain?

What makes your pain worse?

Do you or your child have any other recurrent or persistent pains? (headaches, joint pain?)
□ Yes □ No
B. DIAGRAM OF PAIN AREAS:
Using this diagram, shade the areas where you feel pain. Place an “X” on the area that
hurts the most:
Circle the words that best describe your pain:
tingling
cramping
exhausting
heavy
stabbing
aching
burning
throbbing
excruciating
sharp
unbearable
numb
Form No. 1194, September 2012
shooting
nagging
deep
continuous
Partners Against Pain
Integrated Pain Services
Chronic Pain Clinic
PATIENT HISTORY FORM
Page 2 of 4
Patient Identification
1. Current level of pain, according to a 0 to 10 pain numerical scale:
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst Pain
2. Overall level of pain over the past week:
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst Pain
C. REVIEW OF SYSTEMS:
Does your pain interfere with your sleep?
0 1
2
3
4
5
6
7
8
9
No affect on sleep
10
Affects Sleep
What time do you usually go to sleep? _____________
What time do you get up in the morning? ___________
Do you wake up at night due to pain? □ Yes
□ No
Do you nap during the day?
□ Yes
□ No If yes, how many hours? _____________________
Do you use any sleep aids?
□ Yes
□ No If yes, what kind and how often? ______________
Does your pain affect your appetite?
0 1 2 3
No affect on appetite
4
5
6
7
8
9
10
Affects Appetite
At the present time, does the pain prevent you or your child from the following:
Attending School
□ Yes □ No
Participating in Sports
□ Yes □ No
Socializing with Friends
□ Yes □ No
Participating in Family Activities
□ Yes □ No
Form No. 1194, September 2012
Partners Against Pain
Integrated Pain Services
Chronic Pain Clinic
PATIENT HISTORY FORM
Page 3 of 4
Patient Identification
D. FUNCTION: BRIEF PAIN INVENTORY (BPI). Circle the one number that describes how, during
the
past 24 hours, pain has interfered with your:
General Activity
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
0 1 2 3
Does not interfere
4
5
6
7
8
9
10
Completely Interferes
Mood
Walking Ability
Normal Work / School Work
Relations with Other People
Sleep
Enjoyment of Life
Reference: Adopted, Cleeland, C. S. (1991). Brief Pain Inventory (Short Form)
BPI Score
/70
E. TREATMENT (CURRENT/PREVIOUS): :
Medications: Please provide us with your current medications dosages and frequency.
Drug
Dosage & Frequency
In the past 24 hours, how much relief have pain treatments or medications provided?
Please circle the percentage that most shows how much relief you have received.
0%
10%
No Relief
20%
30%
Form No. 1194, September 2012
40%
50%
60%
70%
80%
90%
100%
Complete Relief
Partners Against Pain
Integrated Pain Services
Chronic Pain Clinic
PATIENT HISTORY FORM
Page 4 of 4
Patient Identification
Describe any herbal remedies or vitamins you may be taking (indicate dosing):
Physical Treatments: Have you in the past or are you currently participating in any of the following:
□ physiotherapy □ acupuncture □ massage therapy □ chiropractor □ exercise □ herbal medications
□ naturopathy □ nutritional support
□ Yes □ No If so, Name of Provider ______________ Length of Therapy ______________
Psychological Treatments: Do you see a counsellor or psychologist for your pain?
□ Yes □ No If so, Name of Counsellor / Psychologist ______________
Length of Therapy ______________
F. PAST MEDICAL HISTORY:
List Other Medical Conditions or Pain States (e.g. headaches):
Previous Trial of Medications:
Drug
Dosage/Frequency
Length of Therapy
Month/Year of Therapy
G. FAMILY / SOCIAL HISTORY: Tell us about your family.
Do any other members of your family suffer from chronic pain (e.g. chronic headaches/migraines
or fibromyalgia), chronic disease or disability? □ Yes □ No
If so, what type of pain/chronic disease? __________________________________
Who lives with you in your house? List names of brothers and sisters and their ages.
__________________________________________________________________
H. SCHOOL INFORMATION:
Name of School ____________________________
Grade __________________
Days of Missed School in the Past Year: ______
Any Learning Accommodations? Do you have an individual education plan (IEP)? □ Yes □ No
I. OTHER: Driver’s License? □ Yes □ No
Learner’s’ Permit? □ Yes □ No
J. CLINIC GOALS: What are your goals with coming to the clinic? Are there any other points you
feel would be important to discuss during this consultation?
Date: _______________________ Signature: ___________________
Contact Information: e-mail address: _____________________ Cell Phone: _________________
Form Completed by:
□ Parent
□ Child □ Both
Form No. 1194, September 2012