Pain Relief Consultation – Fast Online AssessmentPlease complete this confidential form. Our clinician will review and respond shortly. Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Tell us about the pain you’re experiencing so we can determine the most appropriate treatment. ⚠️ If you answer'Yes' to the questions below, it may suggest that an in-person medical review is needed. Please speak to your GP or call NHS 111 urgently. * Where is the pain located? Head Back Neck Joint Abdomen Dental Other When did the pain start? * Today Past few days 1-2 weeks Ongoing for months How would you describe the pain? * Aching Throbbing Sharp/stabbing Burning Cramping Nerve pain On a scale of 1–10, how severe is the pain? * Is the pain constant or does it come and go? * Constant Comes and Goes Is there anything that makes it better or worse? * Rest Heat/cold Medication Movement Other Please describe your pain in your own words * These questions screen for serious conditions that need urgent face-to-face assessment. * Do you have any of the following? Fever Unexplained weight loss Numbness Weakness Loss of bladder or bowel control Recent injury None of the above Have you been in a serious accident or fall recently? * Yes No Have you been diagnosed with cancer, osteoporosis, or spinal problems? * Yes No Have you taken any medication for this pain? * Yes No If yes, what have you tried? (e.g., paracetamol, ibuprofen, codeine) Did these treatments help? * Yes No Are you currently using any prescription pain relief? * Yes No Please list your current pain medications Are you allergic to any medications? * Yes No If yes, please specify Do you have any of the following conditions? * Liver disease Kidney disease Asthma Stomach ulcers High blood pressure Epilepsy Depression or anxiety None Are you pregnant or breastfeeding? * Yes No Do you take any other regular medications? * Yes No Please list all regular medications (if any) Consent & Declaration * I confirm the information I’ve provided is accurate and truthful. I understand this service is for short-term, non-urgent pain relief only. I agree to use pain medication responsibly and as instructed. I understand I must contact my GP if symptoms worsen, persist, or change. I consent to this information being used for prescribing and clinical review. Thank you. Your consultation has been received. A clinician will review your answers and contact you if treatment is appropriate.
