Pain Assessment

Pain Assessment 

Resident Name:  _____________________________________________                  Date:  ______________________________ 

Primary pain site:  ___________________________________________________________  Date of pain onset  _____/_____/_____ 

                                            (Indicate on body illustration as Site A) 

Brief pain history (resident’s viewpoint or observation)  _______________________________________________________________ 

Location/origin of pain  ________________________________________________________________________________________ 

Pain relief methods tried (check all that apply):     o Medication   o Deep Relaxation   o Heat    o Cold    o Massage 

o Meditation    o Music    o Visual Imagery    Other (specify)  _________________________________________________________ 

Pain is relieved by (describe)  ___________________________________________________________________________________ 

Pain is worsened by (describe circumstances or activities)  ____________________________________________________________ 

___________________________________________________________________________________________________________ 

Times when pain is worse: o Early Morning (pre dawn)    o Morning     o Afternoon     o Evening     o Night 

Activities pain prevents residents from doing  ______________________________________________________________________ 

Associated symptoms (if any)  __________________________________________________________________________________ 

Comments  _________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

            On a Scale of 0 – 10, please rate the resident’s pain: 

         0                  1-3                4-6               7-10 

     No Pain     Mild Pain  Moderate Pain  Severe Pain                                    _____________________ 

Score Each Item Individually and Add for Total Score (0-10) 

Nurses Signature:  _________________________________________________ 

References: 

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM] 

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]