Chronic Pain and Mental Health Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Medical Information
Primary Pain Diagnosis
Duration of Pain (e.g., months/years)
Location(s) of Pain
Average Pain Intensity (0-10)
Current Medications
Mental Health
Any past or current mental health diagnoses
Are you currently receiving mental health treatment?
Yes
No
Anxiety Level (0-10)
Mood/Emotional State
Support System (family, friends, etc.)
Additional Information
What would you like to achieve from treatment?
Other Concerns or Comments