PAIN ASSESSMENT CHECKLIST When discussing your pain with your doctor, he needs to understand what type of pain that you have as well as how it affects your daily life. The pain you are feeling can be hard to describe. This checklist may help your doctor identify what type of pain you are feeling and what your options are for managing your pain. In order to help you describe the pain to your doctor, complete the checklist below and share it with your doctor. 1. I would describe my pain as: (Check all that apply.) __ Pins and needles __ Stabbing/shooting __ Burning __ Aching/throbbing __ Numb __ Sharp __ Uncomfortable numbness and tingling sensations __ Other, please describe __________ 2. My pain worsens: (Check all that apply.) __ In the morning __ In the afternoon __ In the evening __ While sleeping 3. I would rate my pain as: (Use a scale of 0 to 10, with 0 being no pain, and 10 being the worst possible pain) For example: 0 - no pain at all 2 - hurts a little bit 4 - hurts a little more 6 - hurts even more 8 - hurts a whole lot 10 - hurts the worst 4. My pain interferes with my ability to: (Check all that apply.) a. Go up or down stairs. Yes or No b. Get in or out of a car. Yes or No c. Get in or out of bed. Yes or No d. Play with kids/grandkids. Yes or No e. Perform heavy chores Yes or No f. Sleep Yes or No g. Perform daily activities such as: shopping Yes or No cooking Yes or No vacuuming Yes or No bathing Yes or No dressing Yes or No napping Yes or No walking Yes or No standing Yes or No 5. I am taking, or have taken, medication for my pain: __ Yes __ No 6. The medication(s) that I current take, or have taken, for my pain: __ Help(s) me with my pain __ Do(es) not help me with my pain __ Help(s) for a time, then wears of too soon 7. I have been diagnosed with: __ Diabetes __ Shingles __ Fibromyalgia __ Lupus __ Arthritis (indicate what type: ________) The doctors need to: • Understand that we need relief. • That our stabbing, shooting, burning pain affects us 24/7. • Provide us tips on managing our pain, as well as fatigue. Pain Tracking Diary: • Download, print, and fill out the diary. It will help you learn more about your pain and what triggers it. And, it will help your doctor assess how well your current treatment is working. • Go to www.MyNervePain.com to find the Pain Tracking Diary. Taking a Pain Diary to the doctor with you each visit will show him/her about your pain, too.