http://www.cityofhope.org/prc/pain_assessment.asp
http://www.intelihealth.com/IH/ihtIH...87.html#verbal
http://www.painresearch.utah.edu/can.../attachb2.html

B2. Initial Pain Assessment Tool

Date:________________

Patient's name:_______________________ Age:________ Room:_______

Diagnosis:____________________________ Physician:_______________
Nurse:_______________

I. Location: Patient or nurse marks drawing

Drawings of Figures in different positions



II. Intensity: Patient rates the pain. Scale used: ___________
Present:__________________________________________ ________
Worst pain gets:__________________________________________
Best pain gets:___________________________________________
Acceptable level of pain:_________________________________

III. Quality: (Use patient's own words, e.g., prick, ache, burn,
throb, pull, sharp)
__________________________________________________ ________

IV. Onset, duration, variations, rhythms:_____________________
__________________________________________________ ________

V. Manner of expressing pain:________________________________

VI. What relieves the pain?___________________________________

VII. What causes or increases the pain?________________________

VIII. 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, suididal, crying)___________________
Concentration_____________________________________ _________
Other_____________________________________________ _________

IX. Other comments:_________________________________________ __

X. Plan:_____________________________________________ ________
__________________________________________________ ________

Note: May be duplicated and used in clinical practice
Source: McCaffery and Beebe, 1989. Used with permission.

Psychosocial Pain Assessment Form
http://www.cityofhope.org/prc/Psycho...ent%20Form.pdf