PMA

Self Evaluation

If persistent pain is interfering with your life, speak to your doctor. Your physician is your best advocate and can help you find the relief you need. Start the conversation by completing the pain Self Evaluation below. Once finished, you can print out a PDF to share with your doctor or simply send it electronically through email.

Patient Information

> Name:

> Age:

> Gender:

Male Female

Pain Self-Evaluation

> Where are you experiencing pain?

Head
Neck
(L) Arm/Shoulder (R) Arm/Shoulder
Upper Back
Lower Back
(L) Hip (R) Hip
(L) Leg (R) Leg
(L) Knee (R) Knee
(L) Ankle/Foot (R) Ankle/Foot
Other?

> How long has the pain been an issue?

1 Week 1 Month 6 Months 1 Year or More

> How severe is the pain?

Mild Moderate Severe Unbearable

> How would you best describe the pain?

Sharp
Dull
Burning
Electric Shock
Other

> Does the pain have any related effects?

None
Numbness
Tingling
Weakness
Other

> Does the pain interfere with how you feel emotionally?

I feel weak and exhausted
I feel overwhelmed
I feel depressed
I feel anxious
I feel irritated
No, I feel fine emotionally
Other?

> What medical attention or procedures have you received to treat your pain?

None
Primary Care Doctor Visit
Surgical Consult
Physical Therapy
Chiropractor
Surgery
Other?

> What medicine have you taken to treat your pain?

None
Acetaminophen
Tylenol
Nonsteroidal Anti-Inflammatory Drugs
Ibuprofen: Advil, Motrin, Nuprin
Naproxen: Aleve, Naprosyn
COX-2 Inhibitors: Celebrex
Cortisteroids
Dexamethasone, Cortisone, Prednisone
Opioids
Codeine, Morphine, Oxycodone
Muscle Relaxants
Valium, Zanaflex, Soma, Flexeril, Norflex
Anti-Anxiety Drugs
Xanax, Ativan
Antidepressants
Cymbalta, Effexor, Elavil, Pamelor, Pramini
Others?

Print & share with your doctor

Email to your doctor

Simply fill out the form below and we will send your doctor a copy of your pain Self Evaluation along with your personal note.

Your Name

Your E-mail

Doctor's Name

Doctor's E-mail

Doctor's Phone Number

Personal Note

Please contact my doctor to determine if pain management treatment is right for me.

Send

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