Forms relating to Pain

Forms can help your health care provider assess the severity of your pain easily and effectively. There are great forms below:

Brief Pain Inventory Form  

Pain Disability Form  

Pain causes poor sleep and poor sleep increases pain. Try this link for Poor Sleep  

Referral to Fraser Health Pain Clinic 

Pain causes anxiety and depression and pain cannot be managed properly if you have moderate to severe anxiety or depression.

Anxiety: GAD 7 Form

Depression forms – PHQ-9 FORM

Form to assist communication of pain if poor communication evident:


PTSD from trauma causes significant pain, emotional and physical. For information on ComplexPTSD, see the video by Nadine Burke Harris at the end of the Daily Program

PTSD from single or multiple traumas like rape, accidents, or violence, including war trauma can be found at this link, PTSD Form.  

Symptoms of ADHD (attention deficit disorder and hyperactivity) or ADD (attention deficit disorder) can be present if you are in severe chronic pain or emotional distress. Always discuss these issues with hour healthcare provider. Adult ADHD.

Symptoms of Attention difficulties for adults

Prescribing Opioids? Medication    DIRE Score   CAGE Score

 Complex PTSD is often associated with addictions.  Here is a link to a questionnaire relating to problems with addictions to substances. 

There are more forms – see Step 1 . Childhood ACE forms and Childhood experiences forms are very useful. 

Sometimes it is hard for people to communicate pain, especially if there is a language or age barrier, or if a person is intellectually challenged. Use the
Face Scale. Ask the person which face would show someone in pain and then point to different areas of the body to ask how that place feels.