Psychosocial Pain Assessment Form (Page 4 of 8) in pdf

Psychosocial Pain Assessment Form Page 4

Social Support

We believe that pain affects not just you, but your entire family. We'd like to look at ways in which

you've noticed this impact.

1. Who do you turn to when you're uncomfortable or in pain?

Self _________________ Others ______________________ God ___________________________

Name: _________________________________ Relationship: _______________________________

How accessible is this person to you? ___________________________________________________

How helpful is this to you? ___________________________________________________________

2. How comfortable are you sharing your feelings/fears with your loved ones?

What makes this difficult for you?

Describe:

_________________________________________________________________________________

3. How satisfied are you with communication with your doctor/medical team?

Describe:

_________________________________________________________________________________

4. Losing people who are important to us affects us deeply. Have you suffered any recent losses?

Yes___ No ___

Describe:

_________________________________________________________________________________

Breaking up___________

Separation _____________

Divorce____________

Death ________________

Moving away___________

Other _____________

5. Please rate your overall level of concern regarding these social support issues.

Rating (0-10)

(0 = no concern, 10 = greatest concern)

Interviewer

Patient

Significant Other

Social Support

__________

_______________

Psychosocial Pain Assessment Form Page 4