Daily Cancer Pain Management Tracking Chart

A Tool for Monitoring and Communicating Your Pain Experience

Oncology

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Last updated: Mar 24, 2025

Patient Information

Name: _________________________ Date: _____________ Medical Record #: ________________

Pain Scale Guide

0 = No pain 1-3 = Mild pain (annoying, but doesn't interfere with activities) 4-6 = Moderate pain (interferes with some activities) 7-9 = Severe pain (interferes with most activities) 10 = Worst possible pain

Daily Pain Log

Time of Day

Time	Pain Level (0-10)	Location	Description	Medication Taken	Relief (0-10)
Morning
Noon
Evening
Bedtime

Pain Description (check all that apply)

Aching
Burning
Sharp
Throbbing
Shooting
Tingling
Other: __________

Activity Impact

Activities affected by pain today:

Walking
Sleeping
Eating
Daily tasks
Social activities

Side Effects

Note any medication side effects:

Nausea
Drowsiness
Constipation
Other: __________

Notes for Healthcare Team

Questions or concerns: _________________________________ Breakthrough pain episodes: ____________________________

Remember to bring this chart to your next appointment

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