Pain Control Record Chart

Learn about the pain control record chart.

Pain Control Record Chart

Using a pain scale is helpful in describing how much pain you are feeling. You can use this chart (print it out) to rate your pain and keep a record of how well the medication is working. Write the information in the chart. Use the pain intensity scale to rate your pain before and after you take the medicine.

You can use a rating scale to describe:

  • How bad your pain is at its worst.
  • How bad your pain is most of the time.
  • How bad your pain is at its least.
  • How your pain changes with treatment.

Pain Intensity Scale (enter this number in the column "Pain scale rating.")

0 1 2 3 4 5 6 7 8 9 10
No pain Worst pain imaginable

Date Time Pain scale rating Medicine and dose Other pain relief methods Side effects from pain medicine
June 6 (example) 8 am 6 Morphine 30 mg - every 4 hours massage constipation
Use this form to record all medications - not just pain medications - you are now taking. This information will help your doctor keep track of all the mediciations you are taking. (Include any over the counter medications you might be taking)

Medicines Taking Now        Date:______________________________
Medicine Dose How often taken How well is it working? Prescribing Doctor
Use this form to record the pain medications you have taken in the past. It will help your doctor understand what has and what has not worked.

Pain Medicines Taken in the Past

Medicine Dose How often taken How well is it working? Prescribing Doctor
For more, please visit the following areas:


  1. MedicineNet


Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care September 12, 2017

The information above has been provided with the kind permission of the National Cancer Institute. For more information, you may also call the Cancer Information Service, at 1-800-4-CANCER (1-800-422-6237).

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