Cancer Pain Assessment Form
Patient Name
Date
Medical Record Number
Pain Details
Location of Pain
Description of Pain
Onset of Pain
Pain Intensity (0 = No Pain, 10 = Worst Imaginable)
Duration & Frequency
Type of Pain
Acute
Chronic
Breakthrough
Incident
Other
Factors That Increase Pain
Factors That Relieve Pain
Current Medications & Management
Medications Taken for Pain
Effectiveness of Pain Control Measures
Side Effects Experienced
Impact of Pain
How Pain Affects Daily Life
Comments or Additional Observations