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Chronic Pain Assessment Questionnaire - ExchangeCME.com

Chronic pain Assessment QuestionnairePatient Informationq First visit q Follow-up visitAge q 20-29 q 30-39 q 40-49 q 50-59 q 60-69 q 70+Height Weight Sex q Male q Female Race q Caucasian q African American q Hispanic q Asian q OtherPain Diagnosis pain is a patient-specific experience that requires ongoing Assessment and evaluation, both by patients and their providers. This Questionnaire will help assess the two parts of Chronic pain that often change over time, persistent baseline and breakthrough pain . Please take a moment to complete this Please rate your baseline pain by circling the one number that best describes your pain on the average during the past Numeric pain Intensity ScaleMild pain Moderate painSevere pain1B Where do you feel this pain ? (In the diagram below shade in the areas where you experience this pain )BackRightLeftRightFront1C What does the pain feel like?

Pain is a patient-specific experience that requires ongoing assessment will help assess the two parts of chronic pain that often change over time, persistent baseline and breakthrough pain.

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