Pain Assessment

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Form 1.1 Initial Pain Assessment Tool
Date_______________
Patient’s Name________________________________________________________Age__________ Room_____________
Diagnosis___________________________________________

Physician______________________________________
Nurse_______________________________________

1. LOCATION: Patient or nurse mark drawing.

2. INTENSITY: Patient rates the pain. Scale used ____________________________________________________________
Present pain:_________ Worst pain gets:__________ Best pain gets:___________ Acceptable level of pain:___________
3. IS THIS PAIN CONSTANT?_ _____ YES; _____ NO IF NOT, HOW OFTEN DOES IT OCCUR?_____________________
4. QUALITY: (For example: ache, deep, sharp, hot, cold, like sensitive skin, sharp, itchy) _________________________
5. ONSET, DURATION, VARIATIONS, RHYTHMS:____________________________________________________________
_______________________________________________________________________________________________________
6. MANNER OF EXPRESSING PAIN:_______________________________________________________________________
_______________________________________________________________________________________________________
7. WHAT RELIEVES PAIN?________________________________________________________________________________
_______________________________________________________________________________________________________
8. WHAT CAUSES OR INCREASES THE PAIN?______________________________________________________________
_______________________________________________________________________________________________________
9. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)
Accompanying symptoms (e.g., nausea)_ __________________________________________________________________
Sleep_ _________________________________________________________________________________________________
Appetite________________________________________________________________________________________________
Physical activity_ ________________________________________________________________________________________
Relationship with others (e.g., irritability)____________________________________________________________________
Emotions (e.g., anger, suicidal, crying)_____________________________________________________________________
Concentration___________________________________________________________________________________________
Other__________________________________________________________________________________________________
10. OTHER COMMENTS:_________________________________________________________________________________
_______________________________________________________________________________________________________
11. PLAN:_______________________________________________________________________________________________
_______________________________________________________________________________________________________
May be duplicated for use in clinical practice. Copyright Pasero C, McCaffery M, 2008. As appears in Pasero C, McCaffery M. Pain: Assessment and pharmacologic
management, 2011, Mosby, Inc.

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