Chronic Pain Assessment Form
Chronic Pain Assessment Form
Please complete this form to evaluate and identify the severity, duration, and impact of chronic pain on a patient’s daily life.
Name
Birth Date
Gender
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Male
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Female
Age
Weight
Height
Marital Status
Occupation
Part 1
During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?
Is this pain present continuously (most of the day) on most days or would the pain persist if not for the treatment you are receiving?
During the past week, on average, how would you rate your baseline pain on a scale of 0 to 10?
What does the pain feel like?
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Aching
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Annoying
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Beating
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Burning
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Cold
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Cramping
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Crushing
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Dull
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Dreadful
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Hot
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Freezing
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Hurting
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Itchy
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Miserable
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Intense
How long have you experienced this pain?
Where do you feel this pain?
Does anything that you do reduce your pain? If yes, please specify.
Are you taking opioid medications daily?
Part 2
Do you have periods during the day when you have temporary episodes of uncontrolled pain?
How would you rate your breakthrough pain at its worst on a scale of 0 to 10?
Where do you feel this pain?
How long have you experienced this pain?
Is the breakthrough pain the same type of pain as usual pain?
Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?
Physician's Info and Diagnosis
Physician Name
Physician's Diagnosis for the Patient
Date
Physician Signature
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