Postoperative Pain Assessment Form
Please complete this form to report your postoperative pain level, patterns, medication effects, and any recovery concerns.
Pain Intensity
Current pain intensity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain quality or location
Sharp
Dull
Throbbing
Burning
Aching
Cramping
Other
Pain Pattern and Triggers
Pain timing
*
Constant
Intermittent
Only with movement
Only at rest
What makes the pain worse or better?
Movement
Changing position
Walking
Deep breathing or coughing
Rest
Ice
Elevating the area
Pain medicine
Other
Functional Impact
How much does pain limit your recovery activities?
*
Rows
Not at all
Mildly
Moderately
Severely
Walking
1
2
3
4
Sleeping
5
6
7
8
Breathing comfortably
9
10
11
12
General movement
13
14
15
16
Please describe any other pain-related recovery limitations
Medication and Side Effects
Have you taken your prescribed pain medication?
*
Yes
No
Not yet
Did the medication help reduce your pain?
*
Yes, a lot
Yes, somewhat
No
Not sure
Side effects experienced after taking pain medication
Nausea
Drowsiness
Dizziness
Constipation
Itching
Stomach upset
None
Other
Recovery Concerns
Which recovery warning signs are you experiencing?
Fever
Swelling
Redness
Drainage
Worsening pain
None of these
Other
Additional comments or concerns
Submit
Should be Empty: