---
title: Chronic Pain Rehabilitation Program Intake Form Template | Paperform
description: Comprehensive chronic pain program intake form with pain catastrophizing scale, opioid use history, psychological screening, and functional restoration goals. HIPAA considerations apply.
url: "https://paperform.co/templates/chronic-pain-rehabilitation-program-intake-form"
type: static
generatedAt: "2026-03-28T00:43:19.197Z"
---

[← Back to free form templates](/templates/)    ![Chronic Pain Rehabilitation Program Intake Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/chronic-pain-rehabilitation-program-intake-form.png)
    [Preview](https://_preview.paperform.co/ai-template/chronic-pain-rehabilitation-program-intake-form) [Use this template for free](/create?ai-template=chronic-pain-rehabilitation-program-intake-form)    [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Therapist](/templates/role/therapist/)[Physical Therapist](/templates/role/physical-therapist/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Streamline Your Chronic Pain Program Intake with Paperform

Managing chronic pain rehabilitation programs requires thorough, compassionate patient intake that captures clinical detail without overwhelming your patients. This **Chronic Pain Rehabilitation Program Intake Form** template helps pain management clinics, physical therapy practices, and multidisciplinary rehabilitation centers collect comprehensive patient information efficiently and professionally.

#### Why Pain Management Programs Need Better Intake Forms

Traditional paper intake forms for chronic pain programs can span dozens of pages, creating friction before treatment even begins. Patients dealing with chronic pain often face cognitive fog, fatigue, and physical discomfort that make lengthy forms particularly burdensome. Digital intake streamlines this process while ensuring you capture critical clinical information—from pain catastrophizing assessments to opioid use history—in a format that integrates seamlessly with your practice management systems.

#### What Makes This Template Essential for Pain Rehabilitation

This template is specifically designed for chronic pain rehabilitation programs and includes:

 - **Comprehensive pain assessment** with location mapping, intensity scales, and pattern tracking
 - **Pain Catastrophizing Scale (PCS)** elements to assess psychological factors
 - **Detailed medication and opioid use history** with dosage and duration tracking
 - **Psychological screening questions** to identify anxiety, depression, and sleep disturbances
 - **Functional limitation assessment** covering daily activities, work, and social participation
 - **Patient-centered goal setting** for meaningful functional restoration outcomes
 - **Previous treatment history** to avoid duplication and build on past interventions

#### How Paperform Transforms Pain Program Intake

With Paperform's intuitive form builder, you can customize this template to match your specific program protocols, add conditional logic to show relevant follow-up questions based on patient responses, and create a welcoming, on-brand experience that puts anxious patients at ease.

**Smart conditional logic** ensures patients only see questions relevant to their situation—if they indicate current opioid use, additional safety screening questions appear automatically. If they report significant psychological distress, you can route their intake for immediate clinical review.

**Calculation fields** can automatically score pain catastrophizing assessments or functional limitation indices, giving your clinical team instant insights before the first appointment.

#### Seamless Integration with Healthcare Workflows

Once a patient submits their intake form, Paperform can automatically:

 - Send confirmation emails with pre-appointment instructions
 - Sync patient data to your practice management system or EHR
 - Notify clinical staff of high-priority cases requiring immediate review
 - Generate PDF summaries for the patient's medical record

For practices looking to fully automate their intake workflow, **[Stepper](https://stepper.io)** can orchestrate complex processes—like routing new patient data to your scheduling system, creating treatment plan templates based on functional goals, and triggering follow-up assessments at predetermined intervals throughout the rehabilitation program.

#### Built for Healthcare Professionals and Their Patients

This template balances clinical thoroughness with patient experience. The guided format breaks complex assessments into manageable sections, progress indicators show patients how much remains, and the mobile-responsive design ensures patients can complete intake from any device—whether at home before their first visit or in your waiting room.

For multidisciplinary pain programs involving physicians, physical therapists, psychologists, and occupational therapists, collecting standardized intake data ensures every team member has the comprehensive background needed for collaborative treatment planning.

#### Security and Compliance You Can Trust

While Paperform is not HIPAA compliant and should not be used for protected health information requiring HIPAA compliance, it does offer **SOC 2 Type II certification**, ensuring robust security controls for your forms and data. For practices handling sensitive health information, consult with your compliance team about appropriate use cases or consider Paperform for administrative and non-PHI collection workflows.

#### Perfect for Pain Management Clinics and Rehabilitation Centers

Whether you're running a hospital-based chronic pain program, an outpatient physical therapy clinic specializing in pain management, or a multidisciplinary rehabilitation center, this template adapts to your specific program model. Customize sections to reflect your treatment philosophy, add questions about complementary therapies you offer, or integrate outcome measures specific to your program protocols.

#### Get Started in Minutes

With over 500,000 teams worldwide trusting Paperform for professional form solutions, you're joining healthcare providers who have transformed their patient intake experience. Start with this template, customize it to your program's needs, and begin collecting better patient data from day one.

**Ready to modernize your chronic pain program intake?** This template gives you everything you need to replace outdated paper forms with a professional, patient-friendly digital experience that integrates smoothly with your existing healthcare workflows.
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