Pain Control Monitoring Record
(To be accomplished by patient/relative in duplicate and acknowledged by attending MD)
Name: |
Age: |
Sex: |
Contact numbers: |
Pain scoring (0-10
with 0 – totally no pain and 10 – most severe pain) by day and time:
Date |
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Day |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
Morning |
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Afternoon |
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Evening |
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Pain-control
medicines taken (pls. list name, dosage, time taken):
Day |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
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Other pain-control
interventions aside from medicines (pls. list if any. Psychosocial support is
one of them.):
Day |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
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Other monitoring
parameters (Quality of life scale – 0 to 3 with 0 = good, 1 = neutral, 2 = bad
or worst):
Day |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
Sleep |
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Daytime
wakefulness |
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Activities
of daily living |
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Bowel
movements |
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General
feeling |
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Patient’s signature |
Relative’s name and
signature |
Physician’s name and
signature |
Pain Control Monitoring Record
(To be accomplished by attending MD)
Name: |
Age: |
Sex:
|
Contact
numbers: |
Date
of admission: |
Date
of discharge: |
Diagnosis: |
Clinical
stage: |
Pretreatment
Pain Score: |
Posttreatment
Pain Score at discharge: |
Pretreatment
Quality of Life Scale (daily activity): |
Posttreatment
Quality of Life Scale (daily activity) at discharge: |
Pretreatment
Quality of Life Scale (general feeling): |
Posttreatment
Quality of Life Scale (general feeling) at discharge: |
Source
of pain: |
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Cause
of pain: |
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Cancer pain:
somatic/visceral/neuropathic |
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Postop pain |
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Nonspecific (noncancer) pain |
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Others: |
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Treatment
administered: |
Adverse
drug reactions / complications: |
Name and Signature and Date