Pain Assessment Clinic

Patient Data

👤 General Information

Surname

First Name

Sex

Date of Birth

Age (years)

ID / NHS Number

City / Town

Phone

General Practitioner

📋 Visit Data

Visit Date

Visit Type

Pain Physician

Dept / Unit

Case No.

Referring Physician

History

👨‍👩‍👧 Family History

🧬 Physiological History

Occupation

Marital Status

Physical Activity

Smoking

Alcohol

Weight (kg)

Height (cm)

BMI (kg/m²)

Physiological Notes

📖 Past Medical History

Chronic Conditions

Previous Surgeries

Relevant Trauma

🔍 Present Illness

Chief Complaint

Pain Onset

Course

Quality of Life Impact

⚠️ Allergies

Pain Characteristics

📍 Location — Click on the body

Selected areas

Click on the body

Additional location description

Distribution

Dermatomal Myotomal Diffuse Localized

🔢 NRS — Pain Intensity

Current Pain

5

Moderate

0 No pain10 Max

Minimum Pain (last month)

2

Mild

010

Maximum Pain (last month)

8

Severe

010

🎯 Pain Quality

Qualitative descriptors

Burning Lancinating Throbbing Dull/Aching Stabbing Cramping Electric shock-like Squeezing Burning (deep) With tingling With numbness Itching Continuous Intermittent Paroxysmal Pinprick

Clinical Questionnaires

⚠️ Notice: The questionnaires in this section are clinical screening questions inspired by the algological literature and do not constitute validated scales. To use the original standardized instruments, please refer to the cited publications and obtain the appropriate permissions from the authors. Results are for guidance only and do not replace the clinical judgment of the physician.

🧪 Neuropathic Component Screening

ℹ️ Clinical screening questions for the neuropathic component of pain. Interpretation of results is the sole responsibility of the physician.

Patient interview — does the pain have the following characteristics?

Positive responses

—

0 / 10

📚 Clinical questionnaire. For a standardized assessment the clinician may refer to validated scales such as: Bouhassira D, Attal N, et al. DN4 — Douleur Neuropathique 4. Pain. 2005;114(1-2):29-36.

🧬 Neuropathic Symptoms and Signs Screening

ℹ️ Clinical screening questions for symptoms and signs suggestive of neuropathic pain. Interpretation of results is the sole responsibility of the physician.

Weighted score

—

0 / 24

📚 Clinical questionnaire. For a standardized assessment the clinician may refer to validated scales such as: Bennett M. LANSS — Leeds Assessment of Neuropathic Symptoms and Signs. Pain. 2001;92(1-2):147-157.

📊 Pain Functional Interference

ℹ️ Assessment of pain impact on daily activities (0 = no interference, 10 = total interference). Interpretation of results is the sole responsibility of the physician.

Mean interference

—

— / 10

📚 Clinical questionnaire. For a standardized assessment the clinician may refer to validated scales such as: Cleeland CS, Ryan KM. BPI — Brief Pain Inventory (Short Form). Ann Acad Med Singap. 1994;23(2):129-138.

🦴 Functional Disability — Lumbar Spine

ℹ️ Assessment of functional limitation in low back pain across 10 areas of daily living. Interpretation of results is the sole responsibility of the physician.

Functional disability

—

— %

📚 Clinical questionnaire. For a standardized assessment the clinician may refer to validated scales such as: Fairbank JC, Pynsent PB. ODI — Oswestry Disability Index. Spine. 2000;25(22):2940-2952.

🧠 PHQ-4 — Anxiety and Depression Screening

ℹ️ Ultra-brief screening for anxiety and depression. Items 1–2: depressive area. Items 3–4: anxiety area. Interpretation of results is the sole responsibility of the physician.

PHQ-4 Total

—

0 / 12

📚 Public domain clinical questionnaire. Ref.: Kroenke K, Spitzer RL, Williams JBW, Löwe B. PHQ-4 — An ultra-brief screening scale for anxiety and depression. Psychosomatics. 2009;50(6):613-621.

⚖️ Intellectual Property and Copyright

The questionnaires included are clinical screening questions for exclusive use by healthcare professionals and do not integrally reproduce the original instruments.
Where available, bibliographic sources are cited. The intellectual property of the original instruments remains with their respective authors and rights holders.
The adaptation of these questions into an interactive digital clinical screening format constitutes fair and non-infringing use under applicable copyright law.
If a rights holder believes any content infringes their intellectual property, please contact us via e-mail (see footer): we will promptly review and, if necessary, remove the material.

Physical Examination by Region

🩺 Vital Signs

BP (mmHg)

HR (bpm)

T°C

SpO2 (%)

Weight (kg)

Height (cm)

RR (breaths/min)

General condition

📄 Diagnostic Tests / Laboratory

Current Treatment and Clinical Tools

💊 Current Medications

Drug	Dosage	Frequency	Route	Since	Efficacy

🫘 CKD-EPI 2021 — Glomerular Filtration Rate (eGFR)

ℹ️ CKD-EPI 2021 race-free formula (Inker et al., NEJM 2021 — KDIGO 2024). Valid for age ≥18 years. If cystatin C is available, use the combined formula (more accurate for CKD classification).

Serum Creatinine

Age (years)

Biological sex

Cystatin C (mg/L) — optional

Albuminuria — optional (for KDIGO staging)

Urea / BUN (mg/dL) — optional

eGFR Stages — KDIGO 2024

Stage G	eGFR	Description	Follow-up / notes
G1	≥90	Normal or increased	If known renal damage: every 12 months
G2	60–89	Mildly reduced	Every 12 months
G3a	45–59	Mild-moderate reduction	Every 6 months — adjust some medications
G3b	30–44	Moderate-severe reduction	Every 3 months — avoid NSAIDs; reduce gabapentinoids
G4	15–29	Severe reduction	Every 1–3 months — urgent nephrology referral; RRT preparation
G5	<15	End-stage renal disease	Dialysis/transplant — maximum pharmacological caution

Albuminuria stages A1/A2/A3 combine with G to define KDIGO risk (green=low; yellow=moderate; orange=high; red=very high).

🔄 Opioid Conversion — OME Calculator

⚠️ For clinical use only — Guidance values only. Equianalgesic doses are approximate and derived from published literature; they do not constitute prescriptive guidance. Always reduce by 25–50% when switching due to incomplete cross-tolerance. For methadone, conversion is dose-dependent — specialists only. Opioid prescription is regulated by applicable national laws. The prescribing physician bears full responsibility.

📋 Equianalgesic dose table (reference: oral morphine 30 mg/day = 1 OME)

Opioid

Route

Equianalgesic Dose

OME Factor

t½ / Notes

Weak opioids (step 2)

Tramadol

PO/IV

300 mg

× 0.10

4–6 h — max 400 mg/day — serotonergic — avoid in CKD G4-G5

Codeine

OS

200–300 mg

× 0.10

4–6 h — prodrug (CYP2D6) — significant genetic variability

Tapentadol

OS

100 mg

× 0.30

4–6 h (IR) / 12 h (PR) — MOR+NRI — useful in neuropathic pain

Morphine — OME reference drug

Morphine

PO (ref.)

30 mg

× 1.00

4 h (IR) / 8–12 h (SR) — active metabolites M6G (accumulation in CKD)

Morphine

SC/IV

10 mg

× 3.00

3–4 h — ratio PO:SC=3:1 — PO:IV=3:1

Strong opioids — others

Oxycodone

OS

20 mg

× 1.50

4–6 h (IR) / 12 h (CR) — bioavailability ~60–87%

Oxycodone

SC/IV

10–15 mg

× 2.00

3–4 h — ratio PO:IV ≈ 2:1

Hydromorphone

OS

6 mg

× 5.00

4–5 h (IR) / 12–24 h (SR) — hydrophilic; useful for SC route

Hydromorphone

SC/IV

1.5 mg

× 20.0

3–4 h — caution: dosing errors due to high potency

Fentanyl TDT

Patch

12.5–25 mcg/h

mcg/h × 2.4

25 mcg/h ≈ 60 mg oral morphine/day — 72h — useful if oral not tolerated

Buprenorphine TDT

Patch

17.5–35 mcg/h

mcg/h × 1.7

35 mcg/h ≈ 60 mg oral morphine/day — 84–96h — safe in CKD, hepatic elimination

Buprenorphine SL

SL

0.2 mg

× 30.0

6–8 h — 0.2 mg SL ≈ 6 mg oral morphine

Methadone — dose-dependent conversion ⚠️ SPECIALISTS ONLY

Methadone PO

Oral Morphine <100 mg/day:	OME ÷ 5 (ratio 1:5)
Oral Morphine 100–300 mg/day:	OME ÷ 10 (ratio 1:10)
Oral Morphine 300–600 mg/day:	OME ÷ 15 (ratio 1:15)
Oral Morphine >600 mg/day:	OME ÷ 20 (ratio 1:20)

Long and variable t½ 24–36h — accumulation risk — monitor QTc — divide dose and reassess after 5–7 days

🧮 Interactive OME Calculator

Source Opioid

Current Dose

OME — mg oral morphine/day

—

🪜 WHO Analgesic Ladder

Step 1

Non-opioids

NSAIDs, paracetamol, metamizole ± adjuvants

Step 2

Weak opioids

Tramadol, codeine, tapentadol ± adjuvants

Step 3

Strong opioids

Morphine, oxycodone, fentanyl, buprenorphine, methadone ± adjuvants

ℹ️ Sources: OME conversion factors based on: CDC Clinical Practice Guideline for Prescribing Opioids (2022); Nielsen S. et al., Opioid-type drug equivalence, Br J Clin Pharmacol 2017; Mercadante S., Caraceni A., Conversion ratios for opioid switching in the treatment of cancer pain, Curr Opin Oncol 2011; WHO Guidelines on the pharmacological treatment of persisting pain (2012). Methadone conversion factors follow the Ayonrinde–Bridge dose-dependent model. Equianalgesic doses are approximate and vary by patient.

Diagnosis and Treatment Plan

🏷️ Diagnosis

Primary Diagnosis (ICD-10)

IASP Classification

Full Diagnostic Description

Secondary Diagnoses / Pain Comorbidities

Clinical Report

Physician's Signature

—

Date and Stamp

—

Legal Disclaimer: This report is a clinical documentation aid and does not replace the clinical judgment of the physician. Clinical questionnaires, calculators (CKD-EPI, OME) and pharmacological tables are for guidance only. The author disclaims all liability for errors, omissions or damages. Reserved for licensed healthcare professionals. This software is not a medical device under EU Regulation 2017/745 (MDR) and does not bear CE marking. Opioid prescription is regulated by applicable national laws.

Privacy: The data contained in this document are special categories of personal data (Art. 9 GDPR) subject to GDPR (EU) 679/2016 and HIPAA regulations where applicable. The physician is responsible for the custody and processing of the patient's personal and health data.

Clinical Questionnaires: The questionnaires in this tool are clinical screening questions inspired by the literature and do not constitute validated scales. Use of the original instruments (DN4, LANSS, BPI, ODI) requires permission from their respective authors. Rights belong to the respective holders.