Psychosocial Pain Assessment Form Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8Activities of Daily Living
Physical Impact
Often unrelieved pain affects a person's daily routine. How has your pain impacted you in these
activities of daily living?
1. Affecting your sleeping patterns? Yes ____ No ____
Frequent napping _____
Difficulty going to sleep _____
Nightmares _____
Difficulty staying asleep _____
Drowsiness _____
Difficulty waking up _____
Chronic Fatigue _____
Other _____
2. Affecting your eating habits?
Yes_____ No_____
Weight loss/gain _____
Special Diet _____
Loss of appetite _____
Feeding Tube _____
Nausea/vomiting _____
Difficulty swallowing _____
Changes in taste _____
Other _____
3. Affecting your hygiene/elimination habits? Yes _____ No_____
Diarrhea _____
Constipation _____
Catheter _____
Ostomy _____
Difficulty Grooming _____
Incontinence _____
Difficulty Bathing _____
Other _____
4. Affecting your ability to move? Yes_____ No_____
Generalized weakness _____
Limited range of motion _____
Bed bound _____
Wheel chair _____
Crutches/walker/cane _____
Walking/standing _____
Getting in/out of car _____
Climbing stairs _____
Lifting/carrying _____
Other _____
No longer athletic _____
S.O.B. _____
5. Affecting your roles in your family? Yes_____ No_____
In what ways?
________________________________________________________________________________
6. Affecting your sexual functioning? Yes_____ No_____
In what ways?
________________________________________________________________________________
7. Affecting your physical appearance? Yes ____ No_____
In what ways?
________________________________________________________________________________
8. How has your energy level changed? Less__________ Same_________ Improved _________
9. Please rate your overall level of concern regarding these physical changes.
Rating (0-10)
(0 = no concern, 10 = greatest concern)
Interviewer
Patient
Significant Other
Activities of daily living
__________
__________
_______________
5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical