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: ___________
• Worst pain gets: ___________
• Best pain gets: ___________
• Acceptable level of pain: ___________

3. QUALITY: (Use patient’s own words, e.g., prick, ache, burn, throb, pull, sharp) ___________

4. ONSET, DURATION, VARIATIONS, RHYTHMS: ___________

5. MANNER OF EXPRESSING PAIN: ___________

6. WHAT RELIEVES THE PAIN? ___________

7. WHAT CAUSES OR INCREASES THE PAIN? ____________

8. 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 ___________

9. OTHER COMMENTS: ___________

10. PLAN: ___________

(Source: From McCaffery M., & Pasero C: Pain: Clinical manual (2nd ed.) (p. 60). St. Louis: Mosby, with permission.)