Name:  

E-mail: 

Phone:  (xxx-xxx-xxxx)

Age:    

Gender: (Male/Female)

I have a history of physical pain that has lasted years  and months.

My doctors tell me I have been diagnosed with:

My worst pain is in the

but I also have pain in the .

On a scale of 0-100, my pain averages about a + and

in a typical day varies between  and +.

What I do that decreases my pain the most is:

What I do that increases my pain the most is:

I think the reason why I still have pain is because my

In the future, I think it is most likely that my pain will

The most important diagnostic tests I have undergone were

The diagnostic tests showed that:

I have undergone surgeries for my pain problem, the most important of which were

  with my

most recent surgery in the year .

Other surgeries you might want to know about were

I am currently receiving the following treatments for my pain condition:

I have previously received treatments for my pain problem including

The main doctors who are treating my pain are licensed in (e.g., family practice, neurology, rheumatology, pain management, orthopedic surgery)

I am currently taking the following prescribed medications

I have medical problems other than my pain problem including

My main reason for consulting with Dr. Tim is that I want

In a typical 16-hour waking day, I am up and getting things done about hours.

I smoke cigarettes per day and consume caffeinated beverages daily.

My height is:

I weigh pounds.

I exercise times per week by this method .

In terms of gainful employment or legal disability, I am

I currently live with

I would describe my romantic history in the past year as .

In the past, in terms of psychological problems, I have been diagnosed with

I have received treatment with

I have been hospitalized times for psychiatric problems.

In terms of alcohol abuse or chemical dependency, I have a history of

I currently consume drinks of alcohol per week.

I take the following non-prescription drugs

I completed years of school and received my

Currently, I am dealing with the following additional stressful situations

To understand my situation better, it might be helpful if you knew that I