Free Nursing Home Pain Assessment Form Template
Nursing Home Pain Assessment Form
Please fill out this form to help us accurately assess and manage the pain levels of our residents.
Resident Information
Resident Name
Date of Birth
Date of Assessment
Room Number
Assessor's Name
Assessor's Job Title
Pain Location and Description
Pain Location(s)
Check all that apply:
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Head
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Neck
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Back
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Arms
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Legs
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Abdomen
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Chest
Pain Type
Check all that apply:
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Sharp
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Dull
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Throbbing
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Burning
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Aching
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Radiating
Pain Intensity
Select the number that best represents the pain level (0 = No Pain, 10 = Worst Pain Imaginable)
Pain Duration and Frequency
When is the Pain Experienced?
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Constant
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Intermittent
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During certain activities
Duration of Pain Episodes
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Less than 5 minutes
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5-15 minutes
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15-30 minutes
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30+ minutes
Pain Management and Relief
What helps reduce the pain?
Medications Currently Used for Pain
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Name |
Dosage |
Frequency |
|---|---|---|
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Additional Information
Provide any additional comments, notes, etc.
Please check the box below to proceed
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