Chronic pain support form

A familiar digital version of a paper form, designed to help you prepare for your appointment and share the information that matters.

Important: This demo helps you prepare for a conversation with your care team. It does not diagnose, replace clinical advice, or make decisions about treatment.

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1. Digital paper form

One clear page that feels familiar, but is easier to complete, store and share.

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2. Guided form

A calmer step-by-step journey that asks the most relevant questions first.

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3. Conversation support

A governed chat-style tool that helps you explain what pain is like for you.

What this option feels like

This is the closest digital version of a traditional paper form. Everything is on one page, so you can see all the questions before you start.

It is useful if you prefer to take your time, write in your own words, and print or save a copy afterwards.

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Good for patients who want

A simple form that feels familiar
One page they can complete at their own pace
A clear record to discuss with a clinician

Chronic pain support form

Use this form to tell us how pain affects you before your appointment.

You can skip questions that do not apply. A clinician will review your answers with you.

Full name

Date of birth

Where do you feel pain?

How long have you had this pain?

What does the pain stop you doing?

What would you most like help with?

Moving more comfortablySleeping betterDaily tasks at homeMood or confidence

Anything you want the clinician to know before you speak?

Submit form

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Before you start

We explain what the form is for, how your answers are used, and when to contact a clinician urgently.

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During the form

Questions are grouped into clear sections, with plain language and helpful hints.

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After you submit

A copy can be sent to you and made available to the care team before the appointment.

Example sections

The live Gravity Forms version would use the same structure, with accessible labels, clear hint text and simple validation.

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About you

Name, date of birth, contact details, preferred communication method and consent to share information.

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Your pain

Where the pain is, how long it has been there, what it feels like, and what makes it better or worse.

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Daily life

Movement, sleep, work, caring responsibilities, mood, confidence and social activities.

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Your goals

What you would like help with first and what a better week would look like for you.

Chronic pain support form

1. Digital paper form

2. Guided form

3. Conversation support

What this option feels like

Good for patients who want

Chronic pain support form

Before you start

During the form

After you submit

Example sections

About you

Your pain

Daily life

Your goals

Alternative Form Example

About you

Your pain

Daily life