Pain Clinic Patient Progress Note
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1Pain Clinic Patient Progress Note
Date last seen:_________________
How would you best describe your pain? (please check all that apply)
Dull, throbbing, aching
Shock-like, numb or tingling
Burning
Other
Please rate your pain by circling the one number that best describes your pain on the average over the past few
days (While taking your pain medication)
1
2
3
4
5
6
7
8
9
10
What makes your pain worse?
standing
walking
sitting bending or twisting
ice
heat
What makes your pain better?
` standing
walking
sitting bending or twisting
ice
heat
To what degree has pain interfered with the following activities 1=no interference, 10=maximum interference
Your sleep
1….2….3….4….5….6….7….8….9….10
General activity
1….2….3….4….5….6….7….8….9….10
Mood
1….2….3….4….5….6….7….8….9….10
Walking ability
1….2….3….4….5….6….7….8….9….10
Normal work (at home and outside) 1….2….3….4….5….6….7….8….9….10
Relations with others
1….2….3….4….5….6….7….8….9….10
Enjoyment of life
1….2….3….4….5….6….7….8….9….10
Did your pain medicine cause a problem?
None Mild Moderate Severe
List all Medications & dosages you currently take
Nausea
Constipation
Drowsiness
Confusion
Dry mouth
Headache
Weight gain
Sexual problems
Did you achieve your physical goals since your last visit? (activities that your pain prevented you from doing)
No
Didn’t try
almost achieved
achieved
achieved and more
What new goals have you made?
______________________________________________________________________________________________
______________________________________________________________________________________________
Please indicate where your present pain is:
Since your last visit, have you had any changes to:
/// Stabbing
XXX Burning
Your Medical History: _________________________
==== Numbness
000 Pins& Needles
____________________________________________
____________________________________________
Your Surgical History:__________________________
____________________________________________
Have you experienced any major life changes/events:_
____________________________________________
____________________________________________
Please list concerns, in order of importance, that you
would like to discuss today _____________________
___________________________________________
Date___________
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