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 MedicineNet.com areas:

Cancer Pain, A Guide for You and Your Family

Sources:

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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