Patient Name Date Assessor

Pain Location(s) Pain Description

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

Pain Characteristics (e.g. sharp, dull, throbbing) Onset/Timing of Pain

Is pain constant or intermittent?

Constant Intermittent

Aggravating Factors Relieving Factors

Current Analgesia / Pain Treatment

Effectiveness of Pain Relief

Side Effects (if any)

Additional Notes