Chronic Pain Evaluation Form
Patient Information
Full Name
Age
Gender
Male
Female
Other
Prefer not to say
Date
Pain Description
Location(s) of Pain
Duration of Pain (e.g., months/years)
Frequency (e.g., constant, intermittent)
Pain Type (select all that apply)
Sharp
Dull
Throbbing
Burning
Aching
Other
Pain Intensity
Average Pain Level (0 = no pain, 10 = worst pain)
What makes the pain worse?
What makes the pain better?
Current Treatments
List any medications, therapies, or treatments you are using
Are they effective?
Yes
No
Partially
Impact on Daily Life
Briefly describe how chronic pain affects your daily activities, sleep, and mood
Additional Information
Anything else you would like to mention?