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Take Charge of Your Care Explain Your Pain
Pay attention to your pain, and use these tools to tell your care team about it: 1. How long have you had your pain?_ ____________________________________________ 2. Where do you feel the pain?_____________________________________________________ _ _______________________________________________________________________________ 3. Is your pain constant, or does it come and go? (circle one). If it comes and goes: How often do you feel it? _ ___________________________________________________ How long does it last?________________________________________________________ 4. List anything that makes your pain worse:_ ____________________________________ _ _______________________________________________________________________________ _ _______________________________________________________________________________ 5. List anything that makes your pain better:______________________________________ _ _________________________________________________________________________________ 6. If you were taking any pain medication before you came to the hospital: What medication(s) did you take?____________________________________________ Did it help with your pain? ____________________________________________________ Have you ever had a bad reaction to a pain medication?_____________________ 7. Is your pain preventing you from (circle all that apply): taking a deep breath, turning in bed, walking to the restroom, getting restful sleep, getting out of bed, sitting in a chair, eating, any other self-care activities? ___________________________ _ _________________________________________________________________________________ 8. List any other activities that are more difficult or that you can no longer do because of your pain: ___________________________________________________________ _ _______________________________________________________________________________
Circle any words that describe what your pain feels like: Aching
Bloating Burning Cramping Cutting Dull Heavy Itching Numb Pinching Pressing Pulling Sharp Shooting Stabbing Swollen Throbbing Tight Tingling
Use this pain scale to let your care team know how bad your pain is:
Moderate (Yellow) 4 - The pain makes some activities uncomfortable. 5 - The pain interrupts some activities. 6 - The pain is hard to ignore, and I avoid some activities. 7 - The pain is the focus of my attention and prevents many activities.
Mild (Green) 0 - I have no pain. 1 - I hardly notice the pain. 2 - I’m aware of the pain, but it’s not distracting. 3 - The pain sometimes distracts me.
Severe (Red) 8 - The pain is awful, and it’s hard to do anything. 9 - I can’t bear the pain, and I can’t do anything. 10 - The pain is as bad as it could be.
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