Pain Medication Effectiveness Evaluation Form
Please complete this form to help us understand how well your pain medication is working and any effects you are experiencing.
Name of Medication
*
Dosage Taken (mg)
*
Date and Time Medication Was Taken
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Pain Being Treated
*
Please Select
Headache
Back pain
Joint pain
Muscle pain
Nerve pain
Other
Pain Level Before Medication (0 = no pain, 10 = worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain Level After Medication (0 = no pain, 10 = worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
How long did the medication provide relief? (in hours)
*
Did you experience any side effects?
*
Nausea
Drowsiness
Constipation
Dizziness
None
Other
How effective was the medication overall?
*
Very effective
Somewhat effective
Not effective
Additional Comments or Observations
Submit Evaluation
Should be Empty: