Book a consultation

So that we can accurately assess your pain level, make an accurate diagnosis and develop a personalized treatment plan, please complete the form below to book an appointment.

    PERSONAL DATA

    Choose the clinic for your visit:

    MEDICAL QUESTIONNAIRE

    Reason for consultation:

    How long has the pain been more severe?

    How did the pain start?

    Choose the sensation of pain

    Is the pain :

    Please rate your pain by choosing the one number that best describes your pain at its WORST in the past 24 hours.

    Please rate your pain by choosing the one number that best describes your pain at its LEAST in the last 24 hours.

    Please rate your pain by choosing the one number that best describes your pain on AVERAGE.

    Please rate your pain by choosing the one number that tells how much pain you have RIGHT NOW.

    Current pain control medications

    During the last 24 hours, what RELIEF have you received from the treatments or medications you are taking? Indicate the number of improvement obtained.

    Medications that have been tried

    Has cannabis been tried?

    Have non-pharmacological approaches been tried?

    What non-pharmacological approaches have been tried?

    Were they useful?

    Under what circumstances is the pain aggravated?

    Indicate the number that best describes how, during the past 24 hours, pain has interfered with your:

    A. General activity
    B. Mood
    C. Walking ability
    D. Normal work (includes both work outside the home and housework)
    E. Relations with other people
    F. Sleep
    G. Enjoyment of life

    What is your occupation?

    Are you off work?

    Since what date?

    Are you taking anticoagulants?

    Do you suffer from:

    Other medical conditions:

    Do you smoke tobacco?

    Do you smoke cannabis?

    What do you expect from the consultation?

    Upload your medical reports of your X-rays/images, if you have them (magnetic resonance, CT scan, x-ray):

    Find out how we can help.

    We're committed to compassionate care and giving our patients the tools they need to live life to the fullest despite the challenges of chronic pain.

    Contact us today.