
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 |
Medicines Taking Now Date:______________________________
Medicine | Dose | How often taken | How well is it working? | Prescribing Doctor |
Pain Medicines Taken in the Past
Medicine | Dose | How often taken | How well is it working? | Prescribing Doctor |
- Cancer Pain, A Guide for You and Your Family
IMAGES PROVIDED BY:
- MedicineNet
REFERENCES:
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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