Chronic Pain Assessment Form
Patient Name
Date of Birth
Assessment Date
Location of Pain
Duration of Pain
Type of Pain
Sharp
Dull
Aching
Burning
Throbbing
Other
Pain Intensity (0 - No pain, 10 - Worst possible pain)
Factors that Aggravate Pain
Factors that Relieve Pain
Current Pain Medications & Dosages
Impact on Daily Activities
Describe how pain affects daily activities
Additional Notes