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Chronic Pain Assessment Questionnaire Form

A detailed clinical questionnaire that helps physicians document a patient's chronic pain intensity, triggers, location, and response to treatment.

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Page 1

Name

First Name

Last Name

Birthdate

Gender

Male Female Other / Prefer not to say

Age

Weight

Height

Marital Status

Occupation

Page 2

During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?

Yes No

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?

Yes No

During the past week, on average, how would you rate your baseline pain on a scale of 0 to 10?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

What does the pain feel like?

Sharp Dull Burning Throbbing Aching Stabbing

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.

Does anything that you do make your pain worse? If yes, please specify.

Are you taking opioid medications daily?

Yes No

If yes, how often are you taking it?

If yes, which opioid are you taking?

Page 3

Do you have periods during the day when you have temporary episodes of uncontrolled pain?

Yes No

If yes, how often? What time of day do these episodes occur? Please specify.

How would you rate your breakthrough pain at its worst on a scale of 0 to 10?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Where do you feel this pain?

How long have you experienced this pain?

What does the pain feel like?

Sharp Dull Burning Throbbing Aching Stabbing

Do you know what causes these breakthrough pain episodes?

Yes No

If yes, please list the causes.

Is the breakthrough pain the same type of pain as your usual pain?

Yes No

If no, please specify your pain.

Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?

Yes No

To what extent does avoiding activities due to fear of an episode of breakthrough pain compromise your quality of life?

Not at all A little Moderately Quite a bit Extremely

Does anything help lessen the severity of these episodes of breakthrough pain? If yes, please specify.

Do you take any medication(s) because of the breakthrough pain? If yes, please specify.

In the past 24 hours, how long has it taken for your breakthrough pain medication to begin to take effect?

How satisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain?

Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied

Physician Name

First Name

Last Name

Physician's Diagnosis for the Patient

Current Date

Physician Signature

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