Pain Scripts' Medication Consultation Form
Full Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
County
Post Code
Pharmacy Address (This is required if you are being prescribed a controlled drug)
Street Address
Street Address Line 2
City
County
Post Code
Email Address
*
Contact Number
*
Have you been referred by someone?
*
Please Select
Yes
No
Who has referred you? Include their email address if known.
*
Do you know what medication you want?
*
Please Select
Yes
No
What is it?
*
Where is your pain?
*
Please Select
Head
Neck
Shoulder
Elbow
Wrist
Hand
Hip
Lower back
Mid back
Knee
Ankle
Other
Multi joint
How long have you been experiencing this pain?
Up to 3 months
3-6 months
6-12 months
More than 1 year
Please score your pain. 10 being the worst pain ever, 0 being no pain.
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Have you been given a clinical diagnosis for your pain?
*
Please Select
Yes
No
What is your diagnosis?
*
Do you have pins and needles, numbness or tingling down either of your arms?
Please Select
Yes
No
Which arm?
Please Select
Right
Left
Both
Do you have muscle spasms?
Please Select
Yes
No
Do you have pins and needles, numbness or tingling down either of your legs?
Please Select
Yes
No
Which leg?
Please Select
Left
Right
Both
Where is your multi joint pain?
Please tell us anything else you think may be relevant about your pain.
*
Do you have any of the following?
*
Unexplained weight loss
Night sweats
Non-mechanical pain e.g pain when you are at rest
A fever (i.e high temperature)
None of the above
Do you smoke?
*
Please Select
Yes
No
Have you ever been diagnosed with cancer?
*
Please Select
Yes
No
When were you diagnosed? And what type of cancer were you diagnosed with?
*
Have you ever been told you have kidney disease?
*
Please Select
Yes
No
When were you diagnosed? And what type of kidney disease do you have?
*
Have you ever been told you have liver disease?
*
Please Select
Yes
No
When were you diagnosed? And what type of liver disease do you have?
*
Do you have asthma?
*
Please Select
Yes
No
Are you currently taking any medications?
*
Please Select
Yes
No
Please list all your current medications.
Do you have any drug allergies?
*
Please Select
Yes
No
Please list your allergies.
Other than the medical conditions listed above, do you have any other medical conditions?
*
Please Select
Yes
No
What other medical conditions do you have?
Do you want information about your medication sent to your NHS GP?
*
Please Select
Yes
No
What is your NHS GP's name and address?
I hereby certify that the information I have reported in Pain Scripts' Medication Consultation Form, is accurate and truthful. I also understand that Pain Scripts will not be held liable in the event of harm that arises to me, from dishonesty or untruthful responses.
Medication Consultations
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Medication Consultation Fee
£
55.00
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