Comprehensive Pain Management Intake Form

Please correct the errors described below.

Activities and your pain

Relieving and aggravating factors

How do the following affects your pain (check one of each item)

LAYING DOWN

STANDING

SITTING

WALKING

EXERCISE

RELAXATION

BENDING

DRIVING/RIDING

BOWEL MOVEMENTS

Previous Pain Treatment

PRIOR PAIN MEDICATIONS: Please check ALL medications you have ever used in the past for treatment.

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