GPS Score: 2026

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The document is a comprehensive patient intake form for Space City Pain Specialists, detailing the history and physical examination process. It includes sections for personal information, chief complaints, pain assessment scales, medical history, review of systems, and consent for treatment. Additionally, it outlines privacy practices regarding medical information and agreements related to pain management and urine testing. The form emphasizes the importance of accurate reporting of symptoms and previous treatments to facilitate effective pain management.

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Click ‘Get Form’ to open the GPS Score: document in the editor.
Begin by filling in your personal details at the top of the form, including your name, sex, and age. Ensure you use blue or black ink for clarity.
In Section I, shade the areas on the diagrams where you feel pain and mark the most painful spots with an 'X'.
Proceed to Section II and check all words that describe your pain. This helps convey your experience accurately.
In Section III, indicate when your pain occurs by checking the appropriate boxes.
For Section IV, provide detailed answers regarding the history of your present illness, including when the pain began and potential causes.
Complete subsequent sections by circling numbers on scales and checking relevant boxes as instructed throughout the form.

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