Psychosocial Pain Assessment Form (Page 3 of 8) in pdf

Introduction

We 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 medical

and physical ones. We will be looking at the overall impact of pain in your life and asking several

questions to help the Pain Team better understand your personal concerns. The first area we will be

addressing is the economic impact of your pain.

Economic

1. 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 Other

Economic

__________

_______________

Psychosocial Pain Assessment Form Page 3