NUR 111Pain Assessment Questionnaire

Client’s Initials _________ Age ________ Date ______________ Room # ___________

Diagnosis _____________________________________________________________________

Analgesics/Other Drugs for Pain ___________________________________________________

Dosage and Times Given _________________________________________________________

LOCATION (Have client point to or trace area of pain)

______________________________________________________________________________

QUALITY (Have client describe in own words)

______________________________________________________________________________

INTENSITY – Rate pain on a 0 to 10 scale: At present _______ Worst it gets _______

Best it gets _______ One hour after medication _______ONSET

When did the pain first occur? _____________________________________________________

When did this episode start? ______________________________________________________

What time of day does it occur? ___________________________________________________

How often does it occur? _________________________________________________________

How long does it last? ___________________________________________________________

CLIENT’S VIEW OF PAIN

What makes the pain better? (alleviating factors) _____________________________________

______________________________________________________________________________

What makes the pain worse? (aggravating factors) ____________________________________

______________________________________________________________________________

What, if any, symptoms are associated with the pain ? (i.e. nausea, sweating, numbness, etc. )

______________________________________________________________________________

What has been tried in the past for controlling pain? ___________________________________

How did it work? _______________________________________________________________

What is the pain preventing the client from doing? ____________________________________

______________________________________________________________________________

PLAN______________________________________________________________________________

______________________________________________________________________________

NOTE: Refer to p. 516 Skill 11.21 in Concept Skills book