• Chronic Pain Assessment Questionnaire Form

  • Patient Information

  • Birthdate
     - -
  • Gender

  • Part 1

  • During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?
  • 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?
  • What does the pain feel like?
  • Are you taking opioid medications daily?

  • Part 2

  • Do you have periods during the day when you have temporary episodes of uncontrolled pain?
  • What does the pain feel like?
  • Do you know what causes these breakthrough pain episodes?
  • Is the breakthrough pain the same type of pain as your usual pain?
  • Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work?
  • To what extent does avoiding activities due to fear of an episode of breakthroughpain compromise your quality of life?
  • How satisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain?

  • Physician's Info and Diagnosis

  • Current Date
     - -
  • Clear
  • Should be Empty:
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