Daily Cancer Pain Management Tracker

Patient Information

Name: _________________________ Date: _____________ Medical Record #: ______________ Phone: ____________

Pain Scale Reference

0 = No pain 1-3 = Mild pain 4-6 = Moderate pain 7-10 = Severe pain

Daily Pain Log

Morning (6 AM - 12 PM)

Time: ______ Pain Level (0-10): ______ Location of pain: _________________ Medication taken: ________________ Relief achieved (0-10): ___________

Afternoon (12 PM - 6 PM)

Time: ______ Pain Level (0-10): ______ Location of pain: _________________ Medication taken: ________________ Relief achieved (0-10): ___________

Evening (6 PM - 12 AM)

Time: ______ Pain Level (0-10): ______ Location of pain: _________________ Medication taken: ________________ Relief achieved (0-10): ___________

Night (12 AM - 6 AM)

Time: ______ Pain Level (0-10): ______ Location of pain: _________________ Medication taken: ________________ Relief achieved (0-10): ___________

Additional Symptoms

□ Nausea □ Fatigue □ Difficulty sleeping □ Loss of appetite □ Other: ________________

Notes for Healthcare Provider

Bring this completed form to your next appointment

Emergency Contact: ________________ Oncologist: ______________________