Chronic Pain Assessment Questionnaire Form
Patient Information
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Gender
Female
Male
Age
Weight
Height
Marital Status
Occupation
Back
Next
Part 1
Assessment of Persistent Baseline Pain
During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?
Yes
No
Is this pain present continuously (most of the day) on most days or would the pain persist if not for the treatment you are receiving?
Yes
No
During the past week, on average, how would you rate your baseline pain on a scale of 0 to 10?
Mild Pain
1
2
3
4
5
6
7
8
9
Severe Pain
10
1 is Mild Pain, 10 is Severe Pain
What does the pain feel like?
Aching
Agonizing
Annoying
Beating
Burning
Cold
Cramping
Crushing
Cutting
Dreadful
Dull
Exhausting
Flashing
Flickering
Freezing
Hot
Hurting
Intense
Itchy
Miserable
Nauseating
Numb
Piercing
Pinching
Pounding
Pressure
Prickling
Pulling
Pulsing
Radiating
Scalding
Sharp
Shocking
Shooting
Sickening
Sore
Spreading
Squeezing
Stabbing
Stinging
Suffocating
Tearing
Throbbing
Tight
Tingling
Troublesome
Tugging
Unbearable
Other
How long have you experienced this pain?
Where do you feel this pain?
Does anything that you do reduce your pain? If yes, please specify.
Does anything that you do make your pain worse? If yes, please specify.
Are you taking opioid medications daily?
Yes
No
If yes, how often are you taking it?
If yes, which opioid are you taking?
Back
Next
Part 2
Assessment of Breakthrough Pain
Do you have periods during the day when you have temporary episodes of uncontrolled pain?
Yes
No
If yes, how often? What time of day do these episodes occur? Please specify.
How would you rate your breakthrough pain at its worst on a scale of 0 to 10?
Mild Pain
1
2
3
4
5
6
7
8
9
Severe Pain
10
1 is Mild Pain , 10 is Severe Pain
Where do you feel this pain?
How long have you experienced this pain?
What does the pain feel like?
Aching
Agonizing
Annoying
Beating
Burning
Cold
Cramping
Crushing
Cutting
Dreadful
Dull
Exhausting
Flashing
Flickering
Freezing
Hot
Hurting
Intense
Itchy
Miserable
Nauseating
Numb
Piercing
Pinching
Pounding
Pressure
Prickling
Pulling
Pulsing
Radiating
Scalding
Sharp
Shocking
Shooting
Sickening
Sore
Spreading
Squeezing
Stabbing
Stinging
Suffocating
Tearing
Throbbing
Tight
Tingling
Troublesome
Tugging
Unbearable
Other
Do you know what causes these breakthrough pain episodes?
Yes
No
If yes, please list the causes.
Is the breakthrough pain the same type of pain as your usual pain?
Yes
No
If no, please specify your pain.
Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?
Yes
No
To what extent does avoiding activities due to fear of an episode of breakthroughpain compromise your quality of life?
A little
A fair amount
A lot
An extreme amount
Does anything help lessen the severity of these episodes of breakthrough pain? If yes, please specify.
Do you take any medication(s) because of the breakthrough pain? If yes, please specify.
In the past 24 hours, how long has it taken for your breakthrough painmedication to begin to take effect?
min.
How satisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Physician's Info and Diagnosis
Physician Name
First Name
Last Name
Physician's Diagnosis for the Patient
Current Date
-
Month
-
Day
Year
Date
Physician Signature
Submit
Submit
Should be Empty: