Table 2.

Sample Patient Checklist of Pain Management Options

Goal for Pain Symptom Management:
Priorities for Pain Management:
Expectations for Treatments:
Acceptable pain intensity rating:
PAIN VALUES RATING
Please rate the following in order of most important to least important
_____ Total relief of pain (no pain)
_____ To be comfortable
_____ Control over pain (some pain is tolerable as long as can I remain functional)
TREATMENT OPTIONS
MEDICATIONS a	Comments	NON-MEDICATIONS b	Comments
☐ Acetaminophen☐ Select Non-steroidal Anti-inflammatory drugs☐ Opioids☐ Local anesthetic☐ Adjunct medications -Corticosteroids -Biologics☐ Adjuvant medications -Anticonvulsants -Antidepressants☐ Advanced therapies (e.g., radiation therapy, spinal cord stimulation, palliative sedation)☐ Experimental pain medication		☐ Environmental adjustments☐ Aromatherapy☐ Massage☐ Warm/cool compresses☐ Distraction using individualized, therapeutic activities (e.g., music therapy)☐ Acupressure☐ Physical therapy☐ Spiritual support☐ Range of motion☐ Transcutaneous electrical nerve stimulation (TENS)☐ Pain management consult

^aThe medications should also be tailored to type of pain (nociceptive, neuropathic, mixed, and cancer) and to pain severity (mild, moderate, severe). This list can be expanded to be more specific for each category of medications.

^bCertain types of non-medications, particularly those requiring higher cognitive function (e.g., cognitive-behavioral therapy, guided imagery, breathing techniques, biofeedback) or those that may frighten or be uncomfortable (e.g., acupuncture, TENS), may be inappropriate for older adult with dementia. This list can be expanded to include other individualized nonmedication treatments.