Patient Comfort Assessment Guide

Please correct the errors described below.

1. Rate your pain by selecting the number that best describes your pain at its WORST in the last month.

2. Rate your pain by selecting the number that best describes your pain at its LEAST in the last month.

3. Rate your pain by selecting the number that best describes your pain on AVERAGE in the last month.

4. Rate your pain by selecting the number that best describes your pain RIGHT NOW.

List the name of the medication, including the dose. Then, choose the percentage to describe the amount of relief the treatment each medicine provide(s) you.

Add Medication

8. What side effect or symptoms arc you having? (Choose the percentage that best describes your experience during the past week.)

9. Choose the percentage that describes how during the past week your pain has interfered with your ...

The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

Please include any additional information you wish about the above answers. Thank you. ©2009 lnflexxion. Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@infiexxion.com. The SOAPP®-R was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

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