INSTRUCTIONS FOR USE - Pain Resource Center - City of Hope

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Psychosocial Pain Assessment FormPatient: _____________________________________ Age: ____ Date: __________________________Med. Record #: __________________Significant Other: ______________________________________Diagnosis: _____________________________ Primary Physician: _____________________________Pain Syndrome: ______________________________________________________________________Duration of Pain: ___________________________ Assessed by: _______________________________Please circle appropriate descriptors.1. Build: Cachectic Thin Medium Heavy Obese2. Attire: Disheveled Hospitalized Casual Professional3. Eye Contact: Avoided Appropriate Stared4. Attention: Distracted HypervigilantFocused5. Manner: Flat Depressed Distant CooperationEngaging Humorous Dramatic AgitatedAnxious Tearful Sobbing DefensiveSarcastic Argumentative Angry Hostile6. Verbal Expression: Terse Vague Average ArticulateVerbose7. Reasoning Ability: Impaired Age-Appropriate Advanced8. Overall Perspective: Pessimistic OptimisticUnrealistic Realistic9. Impressions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Interventions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Recommendations:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rating (0-10)(0 = no concern, 10 = greatest concern)Interviewer Patient Significant OtherEconomic ___________ ________ _______________Social Support ___________ ________ _______________Activities of daily living ___________ ________ _______________Emotional ___________ ________ _______________Coping ___________ ________ _______________2
IntroductionWe recognize that people are often concerned about the impact of pain on many areas of their lives.Unrelieved pain can cause economic, emotional, spiritual and social problems in addition to medicaland physical ones. We will be looking at the overall impact of pain in your life and asking severalquestions to help the Pain Team better understand your personal concerns. The first area we will beaddressing is the economic impact of your pain.Economic1. How are you supporting yourself financially?Work____________________ Family____________________ Disability __________________Partner___________________ Retirement/Pensions _________ Other______________________Friends___________________ Savings ___________________2. Some people we see are concerned about meeting their economic needs.Which of these are worrisome to you?None ______Housing __________________ Clothing __________________ Prescriptions ________________Food ____________________ Childcare __________________ Insurance ___________________Transportation _____________ Medical bills _______________ Other ______________________3. How has your economic situation changed? Better ________________ Worse _________________Describe:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. How upsetting have these changes been to you?Describe:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. What would be different in your life if you could afford to change it?Describe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Please rate your overall level of concern regarding these economic issues.Rating (0-10)(0 = no concern, 10 = greatest concern)Interviewer Patient Significant OtherEconomic __________ __________ _______________3
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INSTRUCTIONS FOR USE - Pain Resource Center - City of Hope

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