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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

 

 

 

 

 

 

 

Day

1

2

3

4

5

6

7

Morning

 

 

 

 

 

 

 

Afternoon

 

 

 

 

 

 

 

Evening

 

 

 

 

 

 

 

Pain-control medicines taken (pls. list name, dosage, time taken):

Day

1

2

3

4

5

6

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

Daytime wakefulness

 

 

 

 

 

 

 

Activities of daily living

 

 

 

 

 

 

 

Bowel movements

 

 

 

 

 

 

 

General feeling

 

 

 

 

 

 

 

 

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:

 

 

Cause of pain:

 

     Cancer pain: somatic/visceral/neuropathic

 

     Postop pain

 

     Nonspecific (noncancer) pain

 

     Others:

 

 

 

Treatment administered:

 

 

 

 

 

 

Adverse drug reactions / complications:

 

 

 

Name and Signature and Date