Pain Management — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary pain complaint]
Duration: [X] days/weeks/months/years
Location: [Anatomic site(s)]
Current status: Stable / Worsening / Fluctuating

Pain Assessment

Pain Characterization

Primary Pain Site: [Location]

Location: [Specific anatomic area]

• Focal / Diffuse / Radiating
• Radiation pattern: None / [Description]

Quality: [Select all that apply]

• [ ] Aching
• [ ] Sharp
• [ ] Burning
• [ ] Stabbing
• [ ] Throbbing
• [ ] Shooting
• [ ] Cramping
• [ ] Pressure
• [ ] Tingling/numbness
• [ ] Electric shock-like

Intensity (0-10 scale):

• Current: [X]/10
• Worst: [X]/10
• Best: [X]/10
• Average: [X]/10

Timing:

• Onset: Sudden / Gradual
• Duration: Constant / Intermittent
• Frequency: [If intermittent — episodes per day/week]
• Pattern: [Morning stiffness, worsening through day, nocturnal]

Aggravating factors:

• [ ] Movement / Activity
• [ ] Prolonged sitting
• [ ] Prolonged standing
• [ ] Walking
• [ ] Bending/twisting
• [ ] Lifting
• [ ] Weather changes
• [ ] Stress
• [ ] Sleep position
• [ ] Other: [X]

Alleviating factors:

• [ ] Rest
• [ ] Position change: [Specific]
• [ ] Heat
• [ ] Ice
• [ ] Medications: [Which ones help]
• [ ] Activity
• [ ] Other: [X]

Associated symptoms:

• [ ] Numbness
• [ ] Tingling
• [ ] Weakness
• [ ] Muscle spasms
• [ ] Swelling
• [ ] Joint stiffness
• [ ] Bowel/bladder changes
• [ ] Sleep disturbance
• [ ] Mood changes

Secondary Pain Sites (if applicable):

[Repeat characterization for additional pain locations]

Red Flag Assessment

[ ] Unexplained weight loss
[ ] Fever/chills
[ ] Night sweats
[ ] Progressive neurological deficit
[ ] Bowel/bladder dysfunction (acute)
[ ] Saddle anesthesia
[ ] Recent significant trauma
[ ] History of malignancy
[ ] Immunosuppression
[ ] IV drug use
[ ] Pain unrelieved by rest or position
Red flags present: None / [List] — Urgent workup: Yes / No

Functional Assessment

Daily Activities Impact

Work status: Working full-time / Part-time / Modified duty / Disability / Retired

• Occupation: [Type]
• Work limitations: [Specific]
• Days missed due to pain (last month): [X]

ADL impact (0=no difficulty, 10=unable):

• Dressing: [X]/10
• Bathing: [X]/10
• Walking: [X]/10
• Sitting: [X]/10
• Standing: [X]/10
• Climbing stairs: [X]/10
• Sleeping: [X]/10
• Lifting: [X]/10
• Driving: [X]/10

Sleep:

• Hours per night: [X]
• Pain awakens from sleep: Yes / No — [Frequency]
• Restorative sleep: Yes / No

Validated Assessment Tools

Pain Disability Index (PDI): [X]/70
Oswestry Disability Index (if low back): [X]% — [Minimal/Moderate/Severe/Crippled]
PROMIS Pain Interference: [T-score]
Brief Pain Inventory: [Scores]
Other: [X]

Psychosocial Assessment

PHQ-9 (Depression): [X]/27 — [Minimal/Mild/Moderate/Moderately severe/Severe]
GAD-7 (Anxiety): [X]/21 — [Minimal/Mild/Moderate/Severe]
Pain Catastrophizing Scale: [X]/52
Current mental health treatment: None / [Provider, treatment]
History of depression/anxiety: No / Yes — [Treatment]
History of PTSD: No / Yes
Current stressors: [Life stressors, work, family]

Pain History

Onset and Course

Original injury/onset: [Date, mechanism]
Initial treatment: [What was tried]
Course: Progressive / Stable / Fluctuating / Improving
Prior diagnosis: [Working diagnosis if known]

Prior Treatments

Medications Tried:

Medication	Max Dose	Duration	Response	Reason Stopped
[Drug]	[Dose]	[X weeks/months]	[0-100%]	[Reason]
[Drug]	[Dose]	[X]	[Response]	[Reason]

Categories tried:

• [ ] NSAIDs: [Drugs, response]
• [ ] Acetaminophen: [Response]
• [ ] Muscle relaxants: [Drugs, response]
• [ ] Neuropathic agents (gabapentin, pregabalin, duloxetine): [Response]
• [ ] Opioids: [Drugs, doses, response]
• [ ] Topicals: [Types, response]
• [ ] Antidepressants: [Response]
• [ ] Other: [List]

Interventional Procedures:

Procedure	Date	Provider	Response	Duration of Relief
[Type]	[Date]	[Name]	[0-100%]	[X days/weeks/months]

Procedures tried:

• [ ] Epidural steroid injection: [Approach, level, response]
• [ ] Facet joint injection: [Level, response]
• [ ] Medial branch block: [Level, response]
• [ ] Radiofrequency ablation: [Level, response]
• [ ] SI joint injection: [Response]
• [ ] Trigger point injection: [Response]
• [ ] Joint injection: [Joint, response]
• [ ] Nerve block: [Type, response]
• [ ] Spinal cord stimulator trial: [Response]
• [ ] Other: [List]

Physical Therapy:

Prior PT: No / Yes — [Duration, type, response]
Home exercise program: No / Yes — [Compliance]
Current PT: No / Yes — [Provider, frequency]

Other Treatments:

• [ ] Chiropractic: [Response]
• [ ] Acupuncture: [Response]
• [ ] Massage: [Response]
• [ ] TENS unit: [Response]
• [ ] Psychological/CBT: [Response]
• [ ] Other: [List]

Surgical History

Pain-related surgeries:

Procedure	Date	Surgeon	Outcome
[Surgery]	[Date]	[Name]	[Better/Same/Worse]

Fusion hardware: None / [Location, type]
Implants: None / SCS / Intrathecal pump

Opioid Risk Assessment

Current Opioid Use

Currently on opioids: No / Yes

• Medication(s): [List with doses]
• Daily MME: [X] mg
• Duration of use: [X] months/years
• Prescriber: [Name]
• Pharmacy: [Name]

PDMP reviewed: Yes — Date: [X]

• Findings: [Consistent / Concerns: X]

Risk Stratification

ORT (Opioid Risk Tool): [X] — Low (0-3) / Moderate (4-7) / High (≥8)
Risk factors:

• [ ] Personal history of substance abuse
• [ ] Family history of substance abuse
• [ ] Age 16-45
• [ ] History of preadolescent sexual abuse
• [ ] Psychological disease (depression, ADD, OCD, bipolar, schizophrenia)

DIRE Score (if on opioids): [X] — Suitable / Not suitable candidate

Substance Use History

Tobacco: Current / Former / Never — [Pack-years, quit date]
Alcohol: Current / Former / Never

• Quantity: [Drinks per week]
• History of problem drinking: No / Yes

Illicit drugs: Never / Past / Current

• History: [Substances, dates]
• IV drug use: No / Yes

Cannabis: No / Yes — [Medical, recreational]
History of substance use disorder: No / Yes

• Treatment: [Type, dates]
• Recovery status: [Duration sober]

Monitoring Compliance (if on opioids)

Urine drug screen: [Date, results — expected vs unexpected]
Pill counts: [Compliant / Concerns]
Controlled substance agreement: Signed / Needs signing
Follow-up compliance: Good / [Concerns]

Past Medical History

[Relevant conditions]
Cardiac: [HTN, CAD, CHF — relevant for NSAID use]
Renal: [CKD — affects medication choices]
GI: [PUD, GI bleed — NSAID caution]
Hepatic: [Affects drug metabolism]
Respiratory: [OSA, COPD — opioid caution]
Neurologic: [Conditions affecting pain]
Psychiatric: [Depression, anxiety, PTSD]
Fibromyalgia: No / Yes
Sleep apnea: No / Yes — [On CPAP]
Obesity: No / Yes — BMI: [X]

Surgical History

[All surgeries, especially spine and orthopedic]

Medications

Current medications: [Full list with doses]
Pain medications:

• [List all analgesics]

Relevant medications:

• Anticoagulants: [Drug — affects procedures]
• Psychiatric medications: [List]
• Sleep aids: [List]

Allergies

[Drug allergies with reactions]
Contrast allergy: No / Yes
Latex: No / Yes

Family History

Chronic pain conditions: No / Yes — [Relationship]
Substance abuse: No / Yes — [Relationship]
Mental health: No / Yes — [Type, relationship]

Social History

Living situation: [With whom, support]
Employment: [Status, type]
Workers' compensation: No / Yes — [Status]
Litigation: No / Yes — [Status]
Insurance: [Type]
Support system: Good / Fair / Poor
Transportation: [Reliable / Barriers]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Weight: [X] — BMI: [X]

General

Appearance: [Well-appearing, in pain, guarded]
Pain behaviors: [Grimacing, guarding, bracing]
Gait: Normal / Antalgic / [Other]
Assistive device: None / [Cane, walker]

Spine Examination (if applicable)

Cervical:

ROM: Flexion [X]° / Extension [X]° / Rotation [X/X]° / Lateral bend [X/X]°
Tenderness: None / [Location]
Paraspinal spasm: None / [Location]
Spurling's test: Negative / Positive [Side]

Thoracic:

ROM: [Limited / Full]
Tenderness: None / [Location]
Kyphosis: Normal / [Increased]

Lumbar:

ROM: Flexion [X]° / Extension [X]° / Lateral bend [X/X]°
Tenderness: None / [Midline, paraspinal — level]
Paraspinal spasm: None / [Side]
SLR: Negative / Positive [X]° [Side] — Crossed SLR: Neg / Pos
FABER: Negative / Positive [Side]
SI joint tenderness: None / [Side]

Neurological Examination

Motor (0-5):

Muscle Group	Right	Left
Deltoid (C5)	/5	/5
Biceps (C6)	/5	/5
Wrist ext (C6)	/5	/5
Triceps (C7)	/5	/5
Grip (C8)	/5	/5
Hip flexion (L2)	/5	/5
Knee ext (L3-4)	/5	/5
Ankle DF (L4-5)	/5	/5
Great toe ext (L5)	/5	/5
Ankle PF (S1)	/5	/5

Sensory:

Light touch: Intact / [Dermatomal deficit]
Pinprick: Intact / [Deficit]
Vibration: Intact / [Deficit]

Reflexes (0-4):

Reflex	Right	Left
Biceps (C5-6)
Triceps (C7)
Patellar (L4)
Achilles (S1)

Babinski: Downgoing / Upgoing [Side]
Clonus: Absent / Present

Joint Examination (if applicable)

[Targeted joint exam based on complaint]

Special Tests

Waddell signs (non-organic): [X]/5 — [Superficial tenderness, simulation, distraction, regional, overreaction]

Diagnostic Studies Review

Imaging

X-ray: [Date, findings]
MRI: [Date, findings — be specific about levels]
CT: [Date, findings]
EMG/NCS: [Date, findings]
Bone scan: [Findings]
Other: [Studies]

Labs

[If applicable — ESR, CRP, vitamin D, B12, thyroid, etc.]

Assessment

1) [Primary pain diagnosis]

• Location: [Anatomic]
• Duration: [Acute/subacute/chronic]
• Mechanism: [Nociceptive/neuropathic/nociplastic/mixed]
• Severity: [Mild/moderate/severe]

2) [Secondary diagnoses]
3) [Contributing factors — deconditioning, depression, sleep, etc.]
4) Opioid risk: Low / Moderate / High

Treatment Plan

Goals of Treatment

Pain goal: Reduce from [X]/10 to [X]/10 (realistic)
Functional goals:

• [Specific measurable goals]
• [Return to work/activities]
• [Sleep improvement]
• [Reduce medication reliance]

Pharmacological Management

Continue:

• [Current effective medications]

Start:

• [ ] [Medication, dose, instructions]

Adjust:

• [ ] [Medication change]

Discontinue:

• [ ] [Medication, taper if needed]

Opioid plan (if applicable):

• [ ] Not indicated
• [ ] Continue current [Dose, medication]
• [ ] Trial initiation: [Drug, dose, duration of trial]
• [ ] Rotation to: [Drug]
• [ ] Taper plan: [Schedule]

Interventional Procedures

Recommended:

• [ ] Diagnostic block: [Type, level]
• [ ] Therapeutic injection: [Type, level]
• [ ] Radiofrequency ablation: [Level]
• [ ] Spinal cord stimulator evaluation
• [ ] Other: [Procedure]

Prior authorization: [ ] Required — [Status]
Scheduling: [Timeframe]

Physical Therapy

• [ ] PT prescription: [Type, frequency, duration]
• [ ] Home exercise program
• [ ] Aquatic therapy
• [ ] TENS unit

Behavioral/Psychological

• [ ] Pain psychology referral
• [ ] CBT for pain
• [ ] Biofeedback
• [ ] Relaxation training
• [ ] Mindfulness-based stress reduction
• [ ] Psychiatric referral: [For depression/anxiety management]

Other Referrals

• [ ] Spine surgery evaluation
• [ ] Rheumatology
• [ ] Neurology
• [ ] Sleep medicine
• [ ] Addiction medicine
• [ ] Weight management
• [ ] Vocational rehabilitation
• [ ] Other: [Specialty]

Monitoring Plan

• [ ] Urine drug screen: [Frequency]
• [ ] PDMP check: [Frequency]
• [ ] Pill counts: [If indicated]
• [ ] Controlled substance agreement: [Sign/renew]
• [ ] Functional assessment: [Frequency]

Patient Education

• Pain neuroscience education
• Realistic expectations
• Active participation in care
• Importance of multimodal approach
• Medication safety (opioid if applicable)
• When to seek urgent care

Follow-up

Return: [X] weeks for [Purpose]

• Prior to: [Procedure if scheduled]
• Labs/UDS: [Before visit]

Sooner if: [Red flags, medication concerns, significant change]

Communication

Discussed with patient: [Topics covered, understanding]
Report sent to: [Referring physician, PCP]
Controlled substance agreement: [Status]