Pain/Discomfort Assessment Tool

Subjective (Reports)

Primary focus:Location:______________________ Intensity (use pain scale/pictures):______________________
Quality (e.g., stabbing, aching, burning):____________________________ Radiation:____________________________
Frequency:_______________________________________________ Duration:_________________________________________________
Precipitating/aggravating factors:__________________________________________________________________
How relieved: OTC/prescription:____________________________ Nonpharmaceuticals/therapies:___________________________
Associated symptoms (e.g., nausea, sleep problems, photosensitivity):__________________________________
Effect on daily activities:______________ Relationships:____________ Job:____________ 
Enjoyment of life:____________
Additional pain focus/describe:________________________________________________________________________________
Cultural expectations regarding pain perception and expression:
_____________________________________________________________________________________________

Objective (Exhibits)
Facial grimacing:_________ Guarding affected area:_________  Posturing:_________  Behaviors:_________  Narrowed focus:_________ 
Emotional response (e.g., crying, withdrawal, anger):
_________________________________________________________________________________________
Vital sign changes (acute pain): BP:__________________ 
Pulse:__________________ 
Respirations:__________________