B2. Initial Pain Assessment Tool
Date:________________

Patient's name:_______________________ Age:________ Room:_______

Diagnosis:____________________________ Physician:_______________
Nurse:_______________

I. Location: Patient or nurse marks drawing

II. Intensity: Patient rates the pain. Scale used: ___________
Present:__________________________________________________
Worst pain gets:__________________________________________
Best pain gets:___________________________________________
Acceptable level of pain:_________________________________

III. Quality: (Use patient's own words, e.g., prick, ache, burn,
throb, pull, sharp)
__________________________________________________________

IV. Onset, duration, variations, rhythms:_____________________
__________________________________________________________

V. Manner of expressing pain:________________________________

VI. What relieves the pain?___________________________________

VII. What causes or increases the pain?________________________

VIII. Effects of pain: (Note decreased function, decreased quality
of life.)
Accompanying symptoms (e.g., nausea)_______________________
Sleep______________________________________________________
Appetite___________________________________________________
Physical activity__________________________________________
Relationship with others (e.g., irritability)______________
Emotions (e.g., anger, suididal, crying)___________________
Concentration______________________________________________
Other______________________________________________________

IX. Other comments:___________________________________________

X. Plan:_____________________________________________________
__________________________________________________________