Island Health - Nanaimo Regional General Hospital

Pain Management Intake Form

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Step 1 of 6 Autosaved just now

1. Patient Info

2. Pain & Body Map

3. Medical History

4. Treatments & Surgeries

5. Work & Legal Claims

6. Review & Submit

Step 1: Patient Information

Please enter your basic personal details for clinic records.

Full Legal Name *

Date of Birth *

Phone Number *

Email Address

May we contact you via email?

Yes No

Step 2: Pain Area & Severity

Use your mouse (or finger) to shade in the body diagrams where you feel pain.

1. Select Shade Tool:

Rate Your Daily WORST Pain Level (0 = No Pain, 10 = Worst Imaginable)

Rate Your Daily BEST Pain Level (at rest or after medications)

Step 3: Past Medical & Family History

Check conditions that apply to you or your direct family members.

Your Personal Medical Conditions

Arthritis Diabetes Neuropathy High Blood Pressure Heart Disease Depression / Anxiety

Family Medical History

Select family conditions and specify relative(s) (e.g. Mother, Father, Brother, Sister).

Chronic Pain

Arthritis

Mental Health

Step 4: Treatments & Surgeries

List past medical treatments, allied health therapies, major surgeries, and current medications.

Past Major Surgeries / Hospitalizations

Previous Therapies Tried

Physiotherapy Chiropractic Acupuncture Injections / Blocks Massage / IMS Psychological Therapy

Current Medications & Supplements

Step 5: Work, Daily Impact & Claims

Tell us how your pain affects work, daily activities, and if any legal or insurance claims exist.

Employment Status

Active Claims / Legal Actions

Active WorkSafeBC / WCB Claim Active ICBC / Motor Vehicle Accident Claim Involved in legal action related to this pain

Claim / File Number (if applicable)

Step 6: Review & Final Submission

Please review all your entered information before submitting.

Summary of Intake

Patient Name: --

Date of Birth: --

Phone Number: --

Employment: --

Worst Pain Level: --/10

Best Pain Level: --/10

Annotated Body Diagram:

Medications:

None added

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Island Health - Interdisciplinary Pain Management Clinic Prototype (Phase 3 Wizard Demo)

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