Pain & Treatment History

Record how your pain has changed, your treatment history, and caregiver information to share with your doctor—and keep the information you may need handy.

Your general pain history

For these questions, consider the first time you were bothered by chronic pain, lasting more than six months.

In general, would you say your health is: Excellent
Very good
Good
Fair
Have you ever seen a physician who specialized in pain? Yes
No
When did the pain begin? Less than 1 month ago
1-3 months ago
3-6 months ago
6-12 months ago
1-2 years ago
2-5 years ago
5-10 years ago
More than 10 years ago
What seemed to cause the pain? Fall/slipping
Work-related injury
Bending
Lifting
Following illness
Following surgery
Motor vehicle accident
Direct blow
Twisting
Weather
Struck by fallen object
Pushing/pulling
Burn
Unsure/don't remember
No obvious cause
Other
Where was the location of your original pain? Head
Chest
Shoulder
Back of thigh
Face
Abdomen
Arm
Front of thigh
Neck
Pelvis
Wrist
Knee
Mid/upper back
Hip
Hand
Calf
Lower back
Buttock
Elbow
Foot
Total body

Your current pain

Think about the pain you are currently feeling.

When did the current pain begin? Less than 1 month ago
1-3 months ago
3-6 months ago
6-12 months ago
1-2 years ago
2-5 years ago
5-10 years ago
More than 10 years ago
What triggered the current pain? Fall/slipping
Work-related injury
Bending
Lifting
Following illness
Following surgery
Motor vehicle accident
Direct blow
Twisting
Weather
Struck by fallen object
Pushing/pulling
Burn
Unsure/don't remember
No obvious cause
Other
Today my pain feels: Deep
Constant
Surface pain
Intermittent
Where does it hurt? (Check all that apply.) Head
Chest
Shoulder
Back of thigh
Face
Abdomen
Arm
Front of thigh
Neck
Pelvis
Wrist
Knee
Mid/upper back
Hip
Hand
Calf
Lower back
Buttock
Elbow
Foot
Total body
Where does it hurt most? (Choose one.) Head
Chest
Shoulder
Back of thigh
Face
Abdomen
Arm
Front of thigh
Neck
Pelvis
Wrist
Knee
Mid/upper back
Hip
Hand
Calf
Lower back
Buttock
Elbow
Foot
Total body How does this pain feel? Discomfort
Pins and needles
Burning
Sharp pain
Stabbing pain
Tingling
Intense ache
Shooting pain
Radiating pain
Numbness
Mild ache How long can you stand? Less than 5 minutes
6-30 minutes
31 minutes to 1 hour
1-2 hours
Greater than 2 hours How long can you sit? Less than 5 minutes
6-30 minutes
31 minutes to 1 hour
1-2 hours
Greater than 2 hours How long can you walk? Less than 5 minutes
6-30 minutes
31 minutes to 1 hour
1-2 hours
Greater than 2 hours What makes your symptoms worse? Sitting
Standing
Walking
Reaching
Twisting
Depressed mood
Bending
Squatting
Crouching
Coughing/sneezing
Cold
Weather
Exercise (general)
Typing/writing
Lifting
Stress
Fatigue
Other (specify)
Staying in one position

Pain relief

What past treatments have you tried? Did they help? (Check all that apply.)

	Tried	Helped
Physical therapy
Cold therapy
Conditioning exercises
Exercise on own
Heat therapy
Occupational therapy
Strengthening exercises
Stretching exercises
TENS Unit
Botox injections
Ultrasound
Water therapy

	Tried	Helped
Complementary approaches
Acupuncture/acupressure
Aromatherapy
Chiropractic/manipulation
Hypnosis
Magnet therapy
Massage therapy
Nutritional detoxification
Relaxation exercises (deep breathing, yoga, etc.)
Spirituality/faith/prayer
Therapeutic touch (including Reiki)
Vitamin and herbal therapy

	Tried	Helped
Psychological treatment
Biofeedback
Family counseling
General psychological assessment
Group therapy
Hypnosis
Individual counseling
Pain support groups
Pre-surgical psychological assessment
Relaxation exercises (deep breathing, yoga, etc.)
Vocational counseling

	Tried	Helped
Injections/surgery (If you don’t know the type, ask your health care provider.)
Botox injection
Epidural steroids
Implantable drug pump
Nerve block
Neuromuscular stimulator
Implantable Neurostimulator
Spine surgery
Surgery (other)
Trigger point injections

	Tried	Helped
Treatment medications (If you don’t know the type, ask your health care provider.)
Anti-convulsants (Dilatin, Zarontin)
Anti-depressants (Prozac, Celexa)
Muscle relaxants
NSAIDS/Cox 2 inhibitors (ibuprofen-Advil, naprosyn-Aleve)
Opiates (narcotic analgesics)
Sleep medications (Ambien, Restoril)
Tranquilizers (Tranzine, Halcyon)
Other pain medications

	Tried	Helped
Other
Diet changes
Medical detoxification
Other treatments

Additional comments

If you have additional information you would like your doctor to know, please add it here:

Last updated: 24 Nov 2009

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