Chronic Pain Medication Review Form

Full name *

Date of birth *

Please name the medication and dose we have requested for review. *

How regularly do you take the medication you highlighted in the previous question ( once or several times a day etc) and for how long (months / years)? *

Where is the pain located on your body? *

Please describe in your own words, what the pain is like. (sharp, dull, constant, intermittent) *

Please rate pain that you experience on a scale of 1-10 BEFORE taking this medication. (with 1 being very low pain and 10 being extreme ) *

Please rate the overall pain that you experience on a scale of 1-10 after taking this medication ( 1 being very mild pain and 10 being extreme pain) *

How long does the pain relief last for? (hours/min) *

Please describe any triggers you have found that brings on the pain or makes it worse. *

Please describe anything other than medication that helps to relieve the pain? *

Please describe any side effects of taking the pain medication. ( if none , please simply state this ) *

Please describe in your own words, how the pain limits your day-to-day activities? ( eg does it stop you from working, walking , lifting etc . If it doesn't limit you, please simply state this) *

Please list any other painkillers you are taking, either regularly or as required (e.g. paracetamol). *

Please let us know if you have any questions or concerns about the medication that you take. (if none, you can leave this section blank)

If you feel your medication is not providing adequate relief, experiencing significant side-effects or you wish to discuss anything about your pain management further, please don't hesitate to make an appointment with a clinician. By providing this information, it helps us to understand your current pain issue and how it is being managed . In some cases, we may arrange further contact or request to make an appointment to discuss your pain management further *

I have understood the above.

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