Chronic Pain Evaluation Worksheet
Patient Information
Name
Date
Date of Birth
Pain History
Location(s) of Pain
Duration of Pain
Suspected Cause
Pain Description
Type of Pain (e.g., burning, stabbing, aching)
Pain Level (0-10)
What makes it better or worse?
Impact
How does the pain affect daily activities?
How does the pain affect sleep?
Treatment & Medications
Current Treatments
Medications
Effectiveness of Treatments
Additional Notes