MELB PAIN - New Patient Form

Your Payment Details

What type of payment or claim will you require
Type of Payment or Claim*

Self InsuredMedicarePrivate HealthWorkcoverDVATAC Claim
Medicare Claim
Medicare Card Number*
Reference Number*
Valid To Date*
Private Health Insurance
Insurance Fund Name*
Member Number*
Reference Number*
Workcover Claim
Date of Injury*

MonthDayYear
Employer Company
Employer Contact
Employer Tel Number
Employer Fax Number
Insurance Company*
Claim Number*
Case Manager's Name*
Case Mgrs Tel Number*
Case Mgrs Fax Number
DVA Claim
DVA Type*

GoldWhite
Card Number*
TAC Claim
Date of Accident*

MonthDayYear
Claim Number*

Where Is Your Pain Located?
On the diagram, colour the areas where you feel pain and use different colours to describe the pain types.

Sharp Pain (RED), Broad Ache (ORANGE), Pins & Needles (BLUE), Other (GREEN).
Explain the pain marked in the diagram*

Your Pain's Impact

During the past week, how much has pain interfered with your life?
Describe a few activities or hobbies that is limited/affected by your pain - describe the level of limitation *
Click to Select the picture that best describes the pattern of your pain over time*

List the pain medications that you are taking right now (if none add NONE)*

List the pain medications you have tried in the past (if none please add NONE)*

Your Other Pain Treatments

Please describe any other pain treatments and describe whether they were helpful or not. Where no treatment, please add NONE.
Injections & Nerve Blocks*
Physiotherapy, Osteopathy, Psychology, Pain Management Programs*
Surgery*
Heat Packs, Cool Packs, Tens, Acupuncture *
Any other treatments not listed above (describe)*

	Not at all	To a slight degree	To a moderate degree	To a great degree	All the time
I worry all the time about whether the pain will end
I feel I can’t go on
It’s terrible and I think it’s never going to get any better
It’s awful and I feel that it overwhelms me
I feel I can’t stand it anymore
I become afraid that the pain will get worse
I keep thinking of other painful events
I anxiously want the pain to go away
I can’t seem to keep it out of my mind
I keep thinking about how much it hurts
I keep thinking about how badly I want the pain to stop
There’s nothing I can do to reduce the intensity of the pain
I wonder whether something serious may happen

	Not at all	Some of the time	A good part of the time	Most of the time
I found it hard to wind down
I was aware of dryness of my mouth
I couldn’t seem to experience any positive feeling at all
I experienced breathing difficulty (eg excessively rapid breathing, breathlessness in the absence of physical exertion)
I found it difficult to work up the initiative to do things
I tended to overreact to situations
I experienced trembling (e.g. in the hands)
I felt that I was using a lot of nervous energy
I was worried about situations in which I might panic and make a fool of myself
I felt that I had nothing to look forward to
I found myself getting agitated
I found it difficult to relax
I felt down-hearted and blue
I was intolerated of anything that kept me from getting on with what I was doing
I felt I was close to panic
I was unable to become enthusiastic about anything
I felt I wasn’t worth much as a person
I felt I was rather touchy
I was aware of the action of my heart in the absence of physical exertion (e.g. a sense of heart rate increase, heart missing a beat)
I felt scared without any good reason
I felt life was meaningless

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