Daily Cancer Pain Management Schedule

Patient Information

Name: ________________________
Date: _________________________
Medical Record #: ______________

Regular Pain Medications

Morning (6:00 AM - 12:00 PM)

• Long-acting medication: _________________ Dose: _____ Time: _____
• Breakthrough medication: _______________ Dose: _____ Time: _____

Afternoon (12:00 PM - 6:00 PM)

• Long-acting medication: _________________ Dose: _____ Time: _____
• Breakthrough medication: _______________ Dose: _____ Time: _____

Evening (6:00 PM - 12:00 AM)

• Long-acting medication: _________________ Dose: _____ Time: _____
• Breakthrough medication: _______________ Dose: _____ Time: _____

Night (12:00 AM - 6:00 AM)

• Long-acting medication: _________________ Dose: _____ Time: _____
• Breakthrough medication: _______________ Dose: _____ Time: _____

Pain Assessment

Rate your pain level (0-10) before and after taking medication:

• Morning: Before ____ After ____
• Afternoon: Before ____ After ____
• Evening: Before ____ After ____
• Night: Before ____ After ____

Side Effects Tracking

• Nausea: □ None □ Mild □ Moderate □ Severe
• Drowsiness: □ None □ Mild □ Moderate □ Severe
• Constipation: □ None □ Mild □ Moderate □ Severe

Emergency Contact Information

• Oncologist: ___________________ Phone: _______________
• Cancer Center: ________________ Phone: _______________
• Emergency Number: ____________

Notes

Contact your healthcare team immediately if pain becomes severe or uncontrolled