Form preview
The Pain Assessment Form provides a thorough, standardized approach to evaluating patient pain across multiple dimensions. It incorporates the Visual Analog Scale (VAS) for pain intensity rating, a body diagram for pain location mapping, and validated questions about pain quality, duration, and aggravating or relieving factors. This structured assessment helps clinicians establish a baseline and track pain progression over time.
Beyond simple intensity ratings, this form captures the functional impact of pain on daily activities, sleep quality, mood, and work capacity. It includes fields for documenting current and past pain treatments, medication history, and patient-reported outcomes. The multi-dimensional approach ensures that pain is assessed not just as a symptom but as a condition affecting overall quality of life.
Ideal for pain management clinics, orthopedic practices, rehabilitation centers, primary care offices, and any healthcare setting where systematic pain documentation is needed. This form supports evidence-based treatment planning and is suitable for both initial evaluations and follow-up reassessments.
What's included
- Visual Analog Scale (VAS) pain intensity rating
- Body diagram for multi-site pain location mapping
- Pain quality descriptors (sharp, dull, burning, aching)
- Functional impact assessment on daily activities and sleep
- Medication and treatment history section
- Aggravating and relieving factor documentation
- Structured medication list with dosage and frequency tracking
Who uses this template
- Initial pain evaluation at pain management clinics
- Pre-operative and post-operative pain monitoring
- Chronic pain reassessment during follow-up visits
- Worker's compensation and disability pain documentation
All form fields
12 fields across 2 pages. Customize any field after signing up.
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