Pain Management New Patient Consultation Note

Date: [Date]
Encounter Type: new patient consultation — [in-person / telehealth]
Clinician: [Clinician name and credentials]
Location: [Clinic site or telehealth location]
Referral Source and Reason: [Referring clinician/service and specific reason]
Primary Pain Region(s): [Primary pain region(s)]
Communication Accommodations: [Interpreter, assistive device, plain language, other] (Only include if applicable.)

Chief Complaint

[Chief complaint(s) in patient's words when helpful; list top one to three]

History of Present Illness

[Opening narrative summarizing onset and precipitating event if any, course over time, reason seeking care now, main functional limitation, and primary treatment goal] (Compose as one cohesive paragraph.)

Location and Radiation: [Location and radiation pattern]
Quality: [burning / aching / electric / stabbing / pressure / cramping / sharp / dull / other]
Severity: current [0–10], average [0–10], worst [0–10] (Use functional anchors when provided.)
Temporal Pattern: [constant / intermittent]; [diurnal variation]; [flare frequency and duration]
Aggravating/Relieving Factors: [Aggravating factors]; [relieving factors]
Associated Symptoms: [numbness / tingling / weakness / autonomic features / sleep disturbance / other]
Self-Management Tried: [heat / ice / bracing / assistive devices / OTC medications / other]

Functional Baseline

Validated Instrument(s): [Instrument name, score, date] (Include at least one reproducible measure such as PEG: Pain 0–10, Enjoyment interference 0–10, General activity interference 0–10. Add condition-specific measures like Oswestry or NDI when relevant.)

• Work status: [working full duty / modified duty / not working / disability / workers' compensation; brief details]
• ADL/IADL limitations: [Specific tasks impacted]
• Sleep quality: [Onset/maintenance issues; hours per night; awakenings due to pain]
• Mobility tolerance: walking [distance/duration], standing [duration], sitting [duration]

Red Flags and Safety Screen

• Constitutional symptoms (fever, night sweats, unexplained weight loss): [present / absent / unknown]
• Cancer history or immunosuppression: [present / absent / unknown]
• Progressive neurologic deficit: [present / absent / unknown]
• Bowel or bladder changes or saddle anesthesia: [present / absent / unknown]
• Significant trauma or fracture risk: [present / absent / unknown]
• Severe uncontrolled night pain: [present / absent / unknown]
• Anticoagulation/antiplatelet therapy: [yes / no / unknown] — [agent(s), dose, indication, last dose] (Include if procedures are being considered.)

Prior Evaluation and Treatment History

(Synthesize records reviewed. If records unavailable, document Records requested.)

• Prior diagnoses: [Diagnosis and source/clinician]
• Imaging: [Modality, region, date, facility, key findings; images personally reviewed vs report only]
• Prior specialist evaluations: [Specialty, date, key recommendations]
• Relevant surgeries: [Procedure, level/region, date, outcome]
• Prior procedures/injections: [Type, level/target, laterality, date, response magnitude and duration]
• Medication trials:
  • Nonopioid analgesics (NSAIDs, acetaminophen, topicals): [name, dose, duration, response, reason stopped]
  • Neuropathic agents (gabapentinoids, SNRIs, TCAs): [name, dose, duration, response, reason stopped]
  • Muscle relaxants: [name, dose, duration, response, reason stopped]
  • Opioids: [formulation, dose, daily MME, prescriber, response, reason stopped or continued]
• Rehabilitation therapies (PT/OT): [type, frequency, duration, outcomes]
• Behavioral or complementary therapies: [CBT, mindfulness, acupuncture, other; response]

Current Medications and Allergies

• Active medications: [Name, dose, frequency, route, actual use pattern]
• CNS depressants: [benzodiazepines, sedative-hypnotics, gabapentinoids, muscle relaxants with doses] (List specifically if present.)
• Anticoagulants/antiplatelets: [Agent(s) and indication] (Include if procedures may be considered.)
• Controlled substances: [formulation, daily dose, prescriber, daily MME]
• Allergies: [Allergen]: [reaction type — immune-mediated vs intolerance]

(If medication list uncertain, document Patient unsure or Reconciliation pending.)

Medical, Surgical, and Behavioral Health History

• Medical comorbidities relevant to pain care: [renal/hepatic disease, GI bleed history, cardiopulmonary disease, sleep-disordered breathing, diabetes, obesity, other]
• Surgical history: [spine/joint surgeries, implanted devices (SCS, intrathecal pump, pacemaker/ICD), other relevant]
• Behavioral health: [depression, anxiety, PTSD; prior/current treatment; current symptom status]
• Substance use: tobacco [status], alcohol [quantity/frequency], cannabis [use pattern], history of substance use disorder or overdose [yes/no; details], treatment history [if applicable] (Use nonjudgmental language.)

Social History

• Occupation and work demands: [role, physical demands, schedule]
• Disability or workers' compensation status: [details] (Include if relevant.)
• Living situation and supports: [household composition, caregiver availability]
• Transportation barriers: [present / absent; details]
• Current activity level: [exercise, hobbies, assistive devices used]

Review of Systems

(Focused on the pain complaint and red flags. Document only systems assessed; do not auto-populate.)

• Pertinent positives: [Positive findings by system]
• Pertinent negatives: [Negative findings by system]

Physical Examination

Vitals: [BP, HR, RR, SpO2, Temp, weight, height] (Include if obtained.)

General: [Appearance, distress level, gait, posture, assistive devices] (Use neutral descriptors for pain behavior.)

Focused Examination:

• Spine: [inspection, ROM with pain reproduction, palpation/tenderness, provocative maneuvers (SLR, FABER, facet loading)] (Include if applicable.)
• Neurologic: [strength by myotome, sensation by dermatome, reflexes, gait (heel/toe/tandem), coordination]
• Joints: [inspection, effusion, warmth, ROM, stability, special tests] (Include if applicable.)
• Myofascial: [trigger points, taut bands, referred pain patterns] (Include if applicable.)

Procedure readiness: Skin integrity at potential sites [intact / compromised — details]. Anticoagulation and implanted device status [confirmed / not applicable].

Data Reviewed

• External records: [source(s) and date(s); key points]
• Imaging: [modality, region, date, facility; key findings; personally reviewed vs report only]
• Laboratory or electrodiagnostic studies: [test, date, key results]
• PDMP review: [date reviewed]; [key findings or no unexpected fills] (Include if opioids are being considered.)
• Toxicology testing: [baseline collected today / prior results with date and findings] (Include if opioids are being considered.)
• Risk screening instruments: [name, score, interpretation] (Scores supplement but do not replace clinical assessment.)

Assessment

[Problem 1]: [Working diagnosis]

• Key supportive findings: [exam and data correlations; pertinent positives/negatives]
• Differential diagnosis: [alternatives if uncertainty remains, or none apparent]
• Pain mechanism: [nociceptive / neuropathic / central sensitization / mixed]

[Problem 2]: [Working diagnosis]

(Include additional problems only if explicitly addressed.)

Global Summary: [Primary pain generator], [major functional limitation], [key risks: medical, behavioral health, medication-related]

Plan

Shared goals: [Measurable functional targets (e.g., walking tolerance, sleep, work tasks)]; reassessment in [timeframe]

• Nonpharmacologic: [PT/OT with specific goals], [home exercise program], [behavioral interventions (CBT/mindfulness)], [sleep optimization], [activity pacing], [weight management] (Include elements addressed.)
• Nonopioid pharmacologic: [agent(s), rationale, dosing, titration plan, monitoring]
• Interventional: [proposed procedure(s) and indication], [prerequisites (imaging review, conservative therapy trial)], [risks/benefits/alternatives discussed], [anticoagulation management plan] (Include if applicable.)
• Opioid therapy: (Include this section only if initiating, continuing, or assuming opioid prescribing.)
  • Indication: [why alternatives insufficient; functional goals]
  • Regimen: [formulation, dose, reassessment interval; taper plan if indicated]
  • Risk-benefit discussion: [documented]; sedative co-prescribing [addressed / not applicable]
  • Safety measures: naloxone [offered / prescribed / declined]; safe storage and disposal [discussed]
  • Monitoring: PDMP [cadence], toxicology [schedule], treatment agreement [signed / pending / in place]
  • Prescribing responsibility: [clinic assuming / not assuming; conditions; coordination with other prescribers]
• Referrals: [specialists, primary care, behavioral health, rehab; communications sent]
• Patient education: [diagnosis explanation], [realistic expectations (function over pain elimination)], [medication safety], [return precautions]

(Avoid language implying automatic continuation or rigid dose escalation. If tapering indicated, document rationale and gradual approach.)

Follow-Up

Timing: [interval, typically 2–6 weeks] — [in-person / telehealth]

Before next visit: [imaging, PT trial, labs/toxicology, procedure scheduling, records to obtain]

To reassess: [repeat functional metrics], [pain intensity], [adverse effects], [progress toward goals]

(For critical elements not obtained today—allergies, medications, baseline scores, red flags, PDMP/toxicology—document as Not assessed, Unknown, or Records requested and plan to address.)