Online Patient Form

Download our patient form in a fillable Pdf here to email back to us at reception@chronicpain.co.za

Pdf can be filled in on your Pc or tablet. No Need to print.

or Fill in the online form below.

Download our financial policy here.

Patient Information

Title

Name

Date of Birth

Age

Tel

Cell No

Occupation

Home Language

No of Dependants

WCA Claim No

Person Responsible for Account

First Names

ID No

Employer

Tel

Cel

Home Addr

Post Addr

Code

Medical Aid

Fund

Medical Aid No

Members Name

Option / Plan

Next of Kin

Name

Relationship

Address

Tel

Referred By

Name

Tel

Address

This account remains your responsibility until fully paid. Regular follow-ups by the member with the medical aid may be required to ensure prompt paymentIn the case of your medical aid not paying the full account, you will be liable for the balance.

Pre-consultation information questionnaire

Have you previously been diagnosed by someone else with any of the following?

Residual / Chronic pain after Shingles

Yes No

Neuropathic pain any where in your body

Yes No

Fibromyalgia

Yes No

Do have an amputation with phantom pain

Yes No

Are you paraplegic with lower body pain

Yes No

CRPS (Complex regional pain syndrome)

Yes No

Failed Back Surgery Syndrome (with low back pain and leg pain)

Yes No

Is your pain due to an injury

Yes No

Where in your body is the pain you are coming to see me about

Chest area

Front Back

Headache

Low back middle

Arm and hand

Buttock pain with or without leg pain

Face pain

Leg pain-whole leg down to toes

Leg pain - upper leg

Low back to either side

Arm pain

How many back operations have you had

Other (not a complete history - JUST where the problem is NOW

A BRIEF history - in order (not too much detail) of what you have already done for the pain

Did You have any previous operations?

By whom was the operation/s performed?

At which hospital/s?

Do You have any medical condition or allergy?

Do You take any pain medication?

Does any of your pain medication cause constipation?

Yes No

Do You take any chronic medication, except for your pain? If Yes, which medication ?

Do You take any, over the counter, medication?

Do You take any vitamins and minerals ?

Have you been previously admitted for pain treatment ?

yes No

Have you ever had psychological treatment for pain?

Yes No

Have you ever been admitted by a psychologist for pain?

Yes No

Who was the psychologist ?

Please check to agree that all information was filled in correctly

Pain Management

Our goal is to offer significant alleviation of pain and help you to live a better life.

we are committed to the recovery of function and the restoration of well-being in a compassionate environment.

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