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Pain Control: Support for People with Cancer

  • Updated: 05/16/2014

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Pain Control Record

You can use a chart like this to keep a record of how well your medicine is working. Some people call it a pain diary. Print out the chart below for writing down your pain. Describe the amount of pain you feel in the way that works best for you. You can use words, numbers on a scale from 0 to 10, or even draw a face (see Talking About Your Pain for examples). Take the chart with you when you visit your doctor.

DateTimeDescribe the pain you feelLevel of pain
8 a.m.stabbing pain in side9
all daydull ache in legs5

Medicines you are taking now

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

DateMedicineDoseHow often takenHow well is it working?Prescribing doctor

Pain medicines you have taken in the past

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

DateMedicineDoseHow often takenSide effectsReason for stopping