← Return to list of consultations

Confidential Pain Management Consultation Form

Don’t let chronic pain keep you from enjoying life!


Pain can take the form of a stress-induced headache, a muscle group strained from sports activities, or be the result of an injury at work or an automobile accident. Pain is the most common symptom for which individuals seek medical help. Acute pain easily can evolve into chronic pain, which can become difficult to treat. Many commonly prescribed, commercially available pain relief medications help the symptoms associated with chronic conditions such as arthritis, fibromyalgia, migraine headaches, and other nerve and muscle pain, but they can also result in unwanted side effects such as drowsiness, dizziness or stomach irritation.

If you feel as though you need help with your chronic pain, fill out our consultation form below or click here to print out PDF version, then fax it back or bring it in. Your privacy is a top priority. This information is secure and is guaranteed to only go directly to the pharmacists.

For your convenience you can send your forms three different ways:

  1. Fill out the online Pain Management form below and sent it straight to us in our secure submission form.
  2. Print and fill out the PDF version for Pain Management and bring it in during your appointment.
  3. Print and fill out the PDF version for Pain Management and fax it to us at 760.834.6297.

Your privacy is a top priority; this information is secure and will only go directly to the pharmacists.

     

    Please complete the form below:
    Fields marked with * are required.

    Name *
    Name
    Birthdate *
    Birthdate
    Must be 18 or older
    Phone *
    Phone
    Feet and inches please
    Precipitating Event
    When your current pain started, was there a precipitating event?
    What is the main problem(s) for which you are seeking treatment?
    Describe what the pain feels like.
    Please indicate the location of your pain with as much detail as possible.
    How long have you had your current pain?
    How often do you have your pain?
    Pain Summary
    Lying Down
    Please indicate how the pain changes with this action:
    Standing
    Please indicate how the pain changes with this action:
    Sitting
    Please indicate how the pain changes with this action:
    Walking
    Please indicate how the pain changes with this action:
    Exercising
    Please indicate how the pain changes with this action:
    Taking Medication
    Please indicate how the pain changes with this action:
    Treatments
    Please indicate all of the treatments you have tried, or are currently using for your pain.
    Please include the following for each: * Name of medication and dosage * Date first prescribed * Daily amount taken * Reason for medication * Physician Name * Did it help with your pain?