Chronic Pain Consult Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Chronic Pain Specialist Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with chronic pain in..., duration of symptoms, relevant comorbidities]

History of Present Illness:
[Detailed description of pain including location, quality, intensity, duration, frequency, aggravating and relieving factors, associated symptoms, impact on function and quality of life]
[Previous treatments tried and response]
[Relevant psychosocial context]

Past Medical History:
(hyphenated list)
- [Chronic conditions]
- [Previous surgeries]
- [Relevant hospitalizations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include pain medications, adjuncts, and other relevant therapies]

Allergies:
(hyphenated list)
- [Drug allergies]
- [Other allergies]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- [Hereditary pain syndromes if relevant]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures, impact of pain on work]
- [Living situation: who lives with patient, home environment]
- [Support systems]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Musculoskeletal: inspection, palpation, range of motion, tenderness, swelling, deformity]
- [Neurological: motor, sensory, reflexes, gait, coordination]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Imaging results with units]
- [Laboratory results with units]
- [Other diagnostic tests]

Assessment & Plan:
[One-sentence patient summary including age, sex, pain diagnosis, and impact]

#) [Pain diagnosis as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered]
- [Medication adjustments or recommendations]
- [Non-pharmacological therapies (e.g., physical therapy, psychological interventions)]
- [Interventional procedures (e.g., injections, nerve blocks)]
- [Counselling discussion]
- [Referrals sent (e.g., physiotherapy, psychology, other specialties)]
- [Follow up plan]
- [Return precautions]