Page 1 of 5 New England Pain Management Consultants 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name, Date of Birth (DOB), and Telephone number in the designated fields. Ensure accuracy as this information is crucial for your medical records.
3. Next, provide details about your Referring Physician and Primary Care Physician, including their telephone numbers and addresses. This helps streamline communication between healthcare providers.
4. In the 'CHIEF COMPLAINT' section, briefly describe the reason for your visit. Use specific terms like 'low back pain' or 'headache' to convey your condition clearly.
5. Proceed to the 'HISTORY OR PRESENT ILLNESS' section. Answer questions regarding the onset of your pain, any accidents or injuries, and whether you are involved in litigation or Worker’s Compensation claims.
6. Complete the pain assessment by indicating where it hurts most on the body chart and circling descriptors that best describe your pain quality. This will assist in understanding your condition better.

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