ASSESSMENT Name: Expectation:

RN:

Date:

Pain History pain level, frequency, pattern (time/environment/activity) Onset Progress Current Aggregating Relieving

Previous Help-Seeking-psycho, physio, alternative Good and Bad Days Typical Activity of Daily Living Family Background family reaction/understanding/helpfulness Occupational Functioning performance, relationship with colleague Financial difficulty YES/NO Social Functioning friend reaction/ understanding/ helpfulness, social activity Impact of pain activity, functioning, psychological before and after onset Psychological Assessment Depression Sadness Pessimism Failure Loss Pleasure Guilt Punishment Self-dislike Self-criticalness Suicidal Crying Agitation Loss interest Fatigue Sex Sleep Appetite

Sex: Sleep: Eat: Anxiety Wobbliness in legs Unable to relax Fear of worst happening Heart pounding/racing Terrified/afraid Nervous Hands trembling Shaking/unsteady Fear of losing control Difficulty in breathing Fear of dying Underlying Thoughts Regarding Pain Pain Pattern mood, stress, relationship, environment, activity, pacing