Psychosocial Pain Assessment Form printable pdf download

Psychosocial Pain Assessment Form

INSTRUCTIONS FOR USE

This tool was designed to standardize a comprehensive psychosocial pain assessment for an

interdisciplinary pain service. Through the use of a guided interview process, the clinician explores the

impact of unrelieved pain on the patient/family experience in the following five domains: Economic,

Social Support, Activities of Daily Living, Emotional Impact, and Coping Style.

Page 1 is designed to provide a synopsis of the patient/family situation for clinical reference and for

presentation at an interdisciplinary pain meeting. It includes the interviewer’s impressions, interventions

and recommendations as well as a summary of the key domains and associated level of concern.

Pages 2-7 contain questions regarding the five domains listed above. Following the questions in each

domain is the opportunity for the patient and family (significant other) to rate their individual level of

concern via a 0-10 rating scale (0 = no concern; 10 = greatest concern). Based upon his/her interpretation

of the interview, the interviewer rates his/her subjective impressions of the patient’s level of concern. If a

family member or significant other is present, his/her rating is then asked and finally the patient’s rating

is obtained. Coherence and discrepancies in ratings between the interviewer, patient and family are noted

and may then be explored for clinical significance.

Additionally, the assessment of prior history (including traumas such as physical and sexual abuse or

unresolved losses) helps a clinician to focus interventions that respect past difficulties as well as past

strengths and coping skills that may be transferable to the current pain experience.

This assessment tool is available in English and in two Spanish versions (children/adolescents and

adults). Contact Shirley Otis-Green, MSW, LCSW () with any questions regarding

usage.

Psychosocial Pain Assessment Form