Cancer Pain Management Questionnaire
Please answer the following questions to help us understand and manage your pain more effectively.
Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Where is your pain located? (You may select more than one area)
*
Head/Neck
Chest
Abdomen
Back
Arms/Hands
Legs/Feet
Other
On a scale of 0 to 10, how would you rate your pain right now? (0 = No pain, 10 = Worst pain imaginable)
*
No pain (0)
0
1
2
3
4
5
6
7
8
9
Worst pain (10)
10
0 is No pain (0), 10 is Worst pain (10)
How long have you been experiencing this pain?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Are you currently taking any pain medications?
*
Yes
No
If you are taking pain medications, please list them and describe how effective they have been. If not, please write 'N/A'.
*
Have you experienced any side effects from your pain medications? (e.g., nausea, drowsiness, constipation)
Nausea
Drowsiness
Constipation
No side effects
Other
How does your pain affect your daily activities? (e.g., sleep, work, movement)
Submit
Should be Empty: