BriefQuestionnaireforPainAssessment

StudyNo._________________ HospitalNo._________________
Donotwriteonthisline
Date: / / Hour:
Lastname: Name:
1. Wehaveallhadpainatsomepointinourlives(e.g.headaches,bruises,toothaches).Currently,haveyoufeltpainthatisdifferent
fromthesecommonpains?
1. Yeah 2.No
2. Indicate on the drawing, with a pencil, where you feel the pain. Indicate with an “X” the part of the body
in which the pain is most severe.

Right Left Left Right

3. Rateyourpainbycirclingthenumberthatbestdescribestheintensity
maximum pain felt in the last 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Theworstpain
Pain Imaginable
4. Rateyourpainbycirclingthenumberthatbestdescribestheintensity
minimum pain felt in the last 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Theworstpain
Pain Imaginable
5. Rateyourpainbycirclingthenumberthatbestdescribesthe average intensity
of pain felt in the last 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Theworstpain
Pain Imaginable

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6. Rateyourpainbycirclingthenumberthatbestdescribestheintensityofyour current pain.
0 1 2 3 4 5 6 7 8 9 10
No Theworstpain
Pain Imaginable
7. Whattreatmentormedicationdoyoureceiveforyourpain?

8. Inthelast24hours,howmuch relief haveyoufeltfromthetreatmentormedication?Circlethepercentagethatbestsuitsyourrelief.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No Relief
Relief Total
9. Circlethenumberthatbestdescribeshow pain has interfered ,duringthepast24hours,withyour:
A. Generalactivity
0 1 2 3 4 5 6 7 8 9 10
No interferes
interferes completely
B. mood
0 1 2 3 4 5 6 7 8 9 10
No interferes
interferes completely
C. Walkingability
0 1 2 3 4 5 6 7 8 9 10
No interferes
interferes completely
D. Normalwork(whetherathomeoroutside)
0 1 2 3 4 5 6 7 8 9 10
No interferes
interferes completely
E. Relationshipswithotherpeople
0 1 2 3 4 5 6 7 8 9 10
Doesnot Completely
interfere interfere
F. Dream
0 1 2 3 4 5 6 7 8 9 10
Doesnot Completely
interfere interfere
g. Funcapacity
0 1 2 3 4 5 6 7 8 9 10
No interferes
interferes completely

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Toolsforinitialpainassessment

Patientlastname Age Roomnumber

Diagnosis Doctor

Right Left
Right Left Right Left
d II d

Left Right

Left right

Right Left

Left Right

I. Location: Thedoctorornursemarksthelocationwithan“x”.

II. Intensity: The patient evaluates the pain. Intensity scale used

Pain at this time:

The worst possible pain:

Best pain level:

Acceptablelevelofpain:

III. Quality: (Use the patient's words, e.g. stinging, continuous, burning, throbbing, stretching, sharp)

IV. Temporalpattern,duration,variation,andrhythm:

V. Ways to express pain:

VI. Whatdoyoudotorelievethepain?

VII. Whatthingsoractivitiescauseorworsenthepain?

VIII. Effectsofpain: (Note functional decrease or decrease in quality of life)

Accompanyingsymptoms(forexample:nausea)
Appetite
Generalactivity
Relationshipswithotherpeople
Emotions(forexample:anger,suicidalthoughts,andcrying)
Concentration
Otherthings

IX. Additionalcomments

X. Plan

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Note: Maybeduplicatedandusedinclinicalpractice
Source: McCafferyandBeebe,1989.Usedwithpermission.
PainDistressScales

SimpleDescriptivePainDistressScale 1
No Annoying Uncomfortable Terrible Awful Torture

NumericalPainDistressIntensityScale 1
NoPain Pain Unbearablepain

0 1 2 3 4 5 6 7 8 9 10

VisualAnalogScale(EVA) 2
NoDistress UnbearableDistress

1
Ifagraphicscaleisused,a10cmlineisrecommended.
2
Itisrecommendedtousea10cmline.onVisualAnalogueScales(VAS)
Source: AcutePainManagementGuidelinePanel,1992.

193
 MemorialPainAssessmentCard
194

1 4
VisualAnalogueScale(VAS) MoodScale
Least Worst Worst Thebest
possible pain possible pain possible mood possible mood

2
3 MoodScale
ReliefScale Moderate Almostnothing

Strong Nopain
Norelief Completerelief
from pain from pain Mild

Verystrong Severe
Weak

Note: Thiscardisdesignedsothateachmeasurementcanbepresentedtothepatientseparatelyandaccordingtonumericalorder.
Source: Fishman,Wallenstein,etal.,1987.Usedwithpermission
PainManagementDiary

Pleaseusethenumericalscaletodescribetheintensityofyourpaininthefollowingdiary.
0 1 2 3 4 5 6 7 8 9 10

Nopain Possiblepain Worst

PainManagementDiaryfor:

Medication or non- Painrating(0-

Painrating(0- pharmacological 10) Activity at
Date Hour 10) intervention you After 1 hour the time of
use to control your pain
pain

201