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| Comprehensive Pain Care Center |
Rate Your Pain
This self-assessment survey may be helpful in determining whether your chonic
pain might be treatable with Pain Therapies. You may want to print this
completed page and take it with you when you see your physician.
Choose a number between 0 and 10 that BEST describes your level of pain
No Pain Worst Pain Possible
0 1 2 3 4 5 6 7 8 9 10
How long have you suffered/experienced pain?
Less than 6 months 6 months - 1 year More than 1 year
Are your pain treatments working to relieve your pain?
Your treatment regimen: Check all that apply.
pain might be treatable with Pain Therapies. You may want to print this
completed page and take it with you when you see your physician.
Choose a number between 0 and 10 that BEST describes your level of pain
No Pain Worst Pain Possible
0 1 2 3 4 5 6 7 8 9 10
How long have you suffered/experienced pain?
Less than 6 months 6 months - 1 year More than 1 year
Are your pain treatments working to relieve your pain?
Your treatment regimen: Check all that apply.
- I take more than one kind of medicine for my pain.
- My pain medicine does not relieve my pain.
- Oral medications, injections, and/or physical therapy have not done enough to relieve my pain.
- Surgery has failed to relieve my pain.
- I have been examined by a medical professional and diagnosed with cancer, nerve damage,
chronic infection, or another chronic condition. - I have visited a pain specialist in an effort to relieve my pain.
- Uncomfortable side effects from current treatments have made life less enjoyable for me and/or my
family. - I have experienced a recent increase or change in my pain.
- Pain prevents me from participating in my usual daily activities.
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