Comprehensive Pain Assessment Tool Do you have pain? Yes No Please focus on your most severe pain and answer the following questions: Where is the pain located? (select all that apply) On my Top Right On my Top Front On my Top Left On my Bottom Right On my Bottom Front On my Bottom Left In my Wisdom Tooth How long has it been hurting for? It’s been there for Hours It’s been there for Days It’s been there for Weeks It’s been there for Months Has it been getting worse? Getting worse Staying the same Gets better with painkillers Off and on How bad is it now? The pain is mild The pain is manageable The pain is very bad The pain is unbearable Have you had recent treatment on this tooth? It’s had a filling in the last week It’s had a filling in the last months It’s had a filling in the last year A tooth was recently taken out A Root filling was started over a month ago A Root filling was started less than a month ago Is it sensitive to hot things? Sensitive to hot, but only while the hot thing touches it Sensitive to hot, and it stays for seconds after Sensitive to hot, and it stays for minutes after Sensitive to hot, and it stays for hours after It’s continuous pain Hot things don’t make a difference Is it sensitive to cold things? Sensitive to cold, but only while the cold thing touches it Sensitive to cold, and it stays for seconds after Sensitive to cold, and it stays for minutes after Sensitive to cold, and it stays for hours after It’s continuous pain Cold water/ice makes the pain go away Cold things don’t make a difference Is the pain affected by biting? Biting on it makes it worse Biting on it makes it better Biting on it makes no difference Describe the pain Sensitive Dull ache Sharp ache Throbbing Electric Anything else makes it worse? Worse in the mornings Worse in the evenings Worse after food Worse when I’m active Worse when I move my head Does it wake you up at night? Can’t sleep Doesn’t affect sleep Does the pain radiate anywhere else? Radiates to my ear Radiates to temple Doesn’t radiate Is the tooth broken? Yes No When did the tooth break? While eating During an accident Don’t know/Not sure What symptoms are present with the broken tooth? Sharp pain on biting Visible crack Pain when temperatures change Submit
