Chronic Pain Form CHRONIC PAIN ASSESSMENT QUESTIONNAIRE Step 1 of 3 33% Name* First Last Height*Weight*Gender*MaleFemaleVisit*First VistFollow-up VisitAge*20-2930-3940-4950-5960-6970+Race*CaucasianAfrican AmericanHispanicAsianOtherMarital Status*Pain is a patient-specific experience that requires ongoing assessment and evaluation, both by patients and their providers. Complete this questionnaire will help assess the two parts of chronic pain that often change over time, persistent baseline and breakthrough pain. Please take a moment to complete this questionnaire.Occupation* PART 1: ASSESSMENT OF PERSISTENT BASELINE PAINYour pain profile may not include persistent baseline pain.Your baseline pain may be uncontrolled. Your physician may need to adjust your baseline treatment.During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?*YesNoIs this pain present continuously (most of the day) on most days or would the pain persist if not for the treatment you are receiving?*YesNoDuring the past week, on average, how would you rate your pain on a scale of 0 to 10?*012345678910Describe where you feel the pain*What does the pain feel like?* Aching Agonizing Annoying Beating Burning Cold Cramping Crushing Cutting Dreadful Dull Exhausting Flashing Flickering Freezing Hot Hurting Intense Itchy Miserable Nauseating Numb Piercing Pinching Pounding Pressure Prickling Pulling Pulsing Radiating Scalding Sharp Shocking Shooting Sickening Sore Spreading Squeezing Stabbing Stinging Suffocating Tearing Throbbing Tight Tingling Troublesome Tugging Unbearing Check all that applyHow long have you experienced this pain?*Please enter a number from 0 to 1000.In weeksDoes anything that you do reduce your pain?*YesNoPlease describe what reduces your pain*Are you taking opioid medications daily?*YesNoWhat are you taking?*How often are you taking it?* You may not be having breakthrough pain. Please see your physician.Do you have periods during the day when you have temporary episodes of uncontrolled pain (also known as breakthrough pain)?YesNoHow often?*What time of day do these episodes occur?*How long does it take from the time you first notice the pain until it is at its worst?*How long does it usually take from the time you take medicine until the pain goes away?*How long do the episodes last?*How would you rate your breakthrough pain at its worst on a scale of a 0 to 10?*012345678910Describe where you feel the pain*What does the pain feel like?* Aching Agonizing Annoying Beating Burning Cold Cramping Crushing Cutting Dreadful Dull Exhausting Flashing Flickering Freezing Hot Hurting Intense Itchy Miserable Nauseating Numb Piercing Pinching Pounding Pressure Prickling Pulling Pulsing Radiating Scalding Sharp Shocking Shooting Sickening Sore Spreading Squeezing Stabbing Stinging Suffocating Tearing Throbbing Tight Tingling Troublesome Tugging Unbearing Check all that applyDo you know what causes these breakthrough pain episodes?*YesNoAre the episodes associated with certain activities (for example: gardening, walking)?*YesNoWhat are these activities?*Does the onset occur with certain bodily functions (for example: coughing, sneezing)?*YesNoWhat are these bodily functions?*Does the onset occur right before a scheduled dose of your pain medication?*YesNoAre these episodes of breakthrough pain the same type of pain as your usual pain?*YesNoHow do they differ?*Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?*YesNoHow often?*To what extent does avoiding activities due to fear of an episode of breakthrough pain compromise your quality of life?*A littleA fair amountA lotAn extreme amountDoes anything help lessen the severity of these episodes of breakthrough pain?*YesNoWhat helps?*What doesn't help?*Do you take any breakthrough pain medication(s)?*YesNoIn the past 24 hours, how long has it taken for your breakthrough pain medication to begin to take effect?*In the past 24 hours, how satisfied or dissatisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain?*Very satisfiedSatisfiedNeutralDissatisfiedVery Dissatisfied
