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Date of entry:________________________
The questionnaire
was: (please circle)
Completed
by patient
Verbally administered
Not done, specify___________________________
Mark
with an "X" on the line below, with the far left
side being "no pain" and the far right side being
"worst pain imaginable", the degree of MOUTH PAIN
you have experienced in the last 24 hours.
No Pain ________________________________________Worst Pain
Mark
with an "X" on the line below, with the far left
side being "no pain" and the far right side being
"worst pain imaginable", the degree of THROAT
PAIN you have experienced in the last 24 hours.
No Pain ________________________________________Worst Pain
Have
you been able to eat: (please circle)
Solids
Liquids
Nothing but pills by mouth
Nothing by mouth
For
the study drug doses, on average, how many minutes were
you able to retain the drug in your mouth? (please circle)
>3 minutes 3 minutes 2 minutes
1 minute Not at all
How
many doses did you swallow yesterday?
One Two
Three Four
In
the last 24 hours, what, if any, medications did you take
for throat and mouth pain? (please circle)
No pain medications were taken for mouth and throat pain
Yes, medications for mouth and throat pain were taken
Name of medication(s):________________________________
In
the last 24 hours, what, if any, pain medications were taken
for reasons other than mouth and throat pain? (please circle)
No pain medications were taken
Yes, medications for pain unrelated to the mouth and throat
were taken
Name of medication(s):________________________________
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