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If a clause on a form or leaflet puzzles you, send that clause exactly as printed. A paraphrase loses the words that matter, so copy the sentence whole and add one line saying where you found it.
If you are in Passaic and want a second look at wording, the quoted text is all you need to copy out. A medical history is not part of it.

Background to bring along
General reading helps when a form uses unfamiliar words. The New Jersey Department of Health homepage is the state's own starting point. An explainer on what a physiatrist is covers one kind of clinician named in pain paperwork. A pain management overview and a pain management news and information hub cover the wider topic.
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