Pain Management Tracking Form

Institution / Company

Date of Treatment

Patient Name / ID #

Use first name and last initial only or ID number for anonymized tracking.

Age

Gender

Male

Female

OtherOther

Sport / Activity Sport / Activity

Injury Assessment

Briefly describe the nature of the injury being treated.

Product Used

Warming Topical

Cooling Topical

Unknown

Application Frequency

e.g. once, twice per game, etc.

Duration of Use

e.g. initial use, use over 2 weeks, etc.

Range of Motion Before

Range of Motion After

Activities Improved

e.g., walking, lifting, bending

Observed Side Effects (if any)

Trainer Name

Observations During Session

Recommendations for Future Use

If you are human, leave this field blank.

Topical Pain Management Effectiveness Tracking Form