Chronic Pain Management Intake Form

Chronic Pain Management Intake Form — Form Fields

This healthcare template includes 10 fields. Comprehensive intake for patients entering a chronic pain management program, covering pain history and treatment background. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email Address (email, required)
• Referring Provider (text, optional)
• Primary Pain Location (dropdown selection, required) — options: Head/neck, Upper back, Lower back, Shoulder, Hip, Knee, Foot/ankle, Abdomen, Widespread (fibromyalgia type), Other
• Pain Duration (multiple choice, required) — options: Less than 3 months, 3-12 months, 1-5 years, Over 5 years
• Average Pain Level in Past Week (1=none, 10=worst imaginable) (rating, required)
• Treatments Previously Tried (checkboxes, optional) — options: Physical therapy, Medications (non-opioid), Opioid medications, Injections/nerve blocks, Acupuncture, Chiropractic, Surgery, Psychological therapy, None
• Has chronic pain affected your ability to work? (multiple choice, required) — options: Yes - unable to work, Yes - reduced capacity, No
• How does your pain affect daily activities? (long text, required)