PEG PAIN SCALE RESULT

Date: [Date]
Patient: [Name or ID, age]
Pain condition: [Main pain diagnosis, site, and how long it has lasted]
Reason for PEG: [Baseline, routine review, opioid therapy review, dose change, or program check-in]
How given: [Paper, patient portal, clinic tablet, or asked aloud; interpreter if used]

PEG SCORE
Average pain, past week: [0 to 10]
Interference with enjoyment of life: [0 to 10]
Interference with general activity: [0 to 10]
Mean of the three: [Sum divided by 3, to one decimal place]
Descriptive level: [None to mild, moderate, or severe]

COMPARED WITH BASELINE
Baseline PEG: [Date and score, and what treatment started then]
Previous PEG: [Date and score]
Change from baseline: [Points and percent; a fall of 30% or more counts as meaningful]

FUNCTION GOALS
Goals agreed: [One to three activities the patient wants back, each with a target]
Progress: [Met, partly met, or not met for each goal, in the patient's words]

TREATMENT AND PLAN
Current pain treatment: [Medicines with doses, physical therapy, exercise, self-management]
Safety review: [For opioid therapy: dose, side effects, monitoring checks, naloxone]
Decision: [Continue, adjust, taper, add or stop a treatment, or refer]
Next PEG: [Date or interval]

Clinician: [Name, credentials]