Appendix I
NATIONAL CANCER INSTITUTE “PAIN CONTROL RECORD”
PAIN
INTENSITY SCALE
Circle the number that best describes the level of pain you are experiencing
Patient name:_________________________________________Week ending: _______________________
| Date | Time | Pain Scale Rating | Medicine and Dose | Other Pain Relief Methods | Side effects From Pain Medicine |
CURRENT MEDICATIONS
This form should be used to record all medications—not just pain medicines—you are now taking. This information will help your doctor keep track of all medicines you are taking.
| Medicines Taking Now | Date:_______________ |
| Medicine | Dose | How Often Taken | How Well is it Working? | Prescribing Doctor |
PAST MEDICATIONS
Used to form to record the pain medicines you have taken in the past. It will help your doctor understand what has and hasn’t worked.
| Pain Medications Taken in the Past |
| Medicine | Dose | How Often Taken | Side Effects | Reason for Stopping |