This next form is to be filled out when starting your pain management program. It is your understanding
of the parameters that are laid out for both of us to engage in the program. This only needs to be filled out once.
Controlled Substance Agreement
Pain Assessment Form
The first is to be used to assess your level of discomfort. If you are not sure
if your scores are one number or another it is OK to circle two or three numbers to estimate your range. To help define
the pain scale numbers use the following guide:
0 No Pain
1-2 Pain that does not interfer with your thoughts or activities.
disabling. The pain is starting to effect your ability to perform the current activitiesd. (i.e. decreased
movement, decreased speed, and/or the need to rest and/or stretch in order to continue completing the current activity).
4 Pain between 4 and 5.
5 Very disabling pain. Causes
great difficulty moving or applying any strength through the painful area. You are unable to complete the current activity.
6 Pain that causes disability between 5 and 7.
Severely disabling pain. You cannot use or move the painful area. You have difficulty talking and concentrating
on anything but the pain. Needing to lie-down and/or pain related tearfulness are common at this level of pain.
8-9 Pain that causes disability between 7 and 10. Nearing need for hopitalization.
10 Worst imaginable pain. Causes you to be completetly incapacitated and barely able to
talk. Requires immediate emergency hospitalization.