Neuropathic Pain Assessment Form

Patient Name

Date of Assessment

Assessor

Onset

Duration

Pain Location

Description of Pain (e.g., burning, shooting, tingling)

Pain Intensity (0 = No Pain, 10 = Worst Pain)

Numbness Tingling Allodynia (pain from non-painful stimuli) Hyperalgesia (increased response to pain) Other

Describe the impact of pain on daily activities

List current medications and dosages