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    Pain Control Record Chart

    Using a pain scale is helpful in describing how much pain you are feeling. You can use this chart (print it out) to rate your pain and keep a record of how well your medicine is working. Write the information in the chart. Use the pain intensity scale to rate your pain before and after you take the medicine.

    You can use a rating scale to describe:

    • How bad your pain is at its worst
    • How bad your pain is most of the time
    • How bad your pain is at its least
    • How your pain changes with treatment

    Pain Intensity Scale (enter a number in the column "Pain scale rating")

    0 1 2 3 4 5 6 7 8 9 10
    No pain Worst pain imaginable

    Date Time Pain scale rating Medicine and dose Other pain relief methods Side effects from pain medicine
    June 6 (example) 8 am 6 Morphine 30 mg - every 4 hours massage constipation

    Use this form to record all medicines - not just pain medicines - you are now taking. This information will help your doctor keep track of all the medicines you are taking.

    Medicines Taking Now Date:______________________________

    Medicine Dose How often taken How well is it working? Prescribing doctor

    Use this form to record the pain medicines you have taken in the past. It will help your doctor understand what has and what hasn't worked.

    Pain Medicines Taken in the Past

    Medicine Dose How often taken How well did it work? Prescribing doctor

    WebMD Medical Reference

    Reviewed by William Blahd, MD on January 16, 2016

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