Wellspring Pain Clinic Sydney | Chronic Pain Management & Treatment

Patient Information

First Name *

Last Name *

Age *

Date of Birth *

Address *

Postcode *

Email Address *

Phone - Mobile *

Phone - Home

Phone - Work

Current specialists and contact details:

If you are currently seeing a psychologist, psychiatrist, or physiotherapist please provide contact details below:

Are you currently:

Employed full timeEmployed part timeUnemployed

Information on your pain symptoms / condition

Please provide as much information as possible on the following questions

How did your pain start?

How has your pain changed since you first noticed it?

What remedies/treatments/surgeries/medications have you tried? Please comment on their effectiveness.

Which statement best describes your pain? (Tick one box only) *

Always present (always the same intensity)Always present (level of pain varies)Often present (pain free periods last less than 6 hours)Occasionally present (pain occurs once to several times per day, lasting up to an hour)Rarely present (pain occurs every few days or weeks)

Health care (other than your visits to the pain clinic)

1. How many times in the past 3 months have you seen a general practitioner in regard to your pain? *

2. How many times in the past 3 months have you seen a specialist in regard to your pain? *

3. How many times in the past 3 months have you seen other health professionals in regard to your pain? *

4. How many times in the past 3 months have you visited emergency departments in regard to your pain? *

(include all visits, regardless of whether or not you were admitted to the hospital from the emergency department)

5. How many times in the past 3 months have you been admitted to hospital in regard to your pain? *

6. How many diagnostic tests have you had in the past 3 months in regard to your pain? *

Pain ratings (0-10)

Please rate your pain by circling the one number that best describes the following (0 = No pain; 10 = Pain as bad as you can imagine) *

Pain characteristics

Does the pain have one or more of the following characteristics?

Medical information

Medications

Are you taking medications? *

NoYes

Additional Documents

Please add an attachment when necessary eg. any imaging/scan results or your comprehensive list of medications if available.

Accepted file types: PDF, JPG, PNG, DOC, DOCX

Online Patient Registration Form

Pain Questionnaire