Pain Assessment

Pain Assessment
Today's Date

MonthDayYear
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email Address
example@example.com
MaleFemale
Age
Height
Weight
Please list any/all allergies:
What is the main problem for which you are seeking treatment?
When your current pain started, was there a precipitating event?

Automobile AccidentWork InjurySurgerySportsOther
How long have you had your current pain problem?

How do the following affect your pain?

	Name of medication and dosage	Date first prescribed	Daily amount taken	Reason for medication	Physician Name	Did this help with your pain? (Put an "X" in column if it helped)
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