Chronic Pain Assessment Form
Patient Information
Full Name
Date of Birth
Date
Pain Description
Pain Location
Duration of Pain
Frequency (e.g., constant, intermittent)
Characteristics (e.g., sharp, dull, burning)
Pain Intensity (0-10)
Aggravating & Relieving Factors
What makes the pain worse?
What improves the pain?
Effects on Daily Life
Impact on mobility/activities
Impact on sleep
Current Pain Management
Medications (name, dose, frequency)
Other Treatments (physical therapy, etc.)
Additional Comments