Psychosocial Pain Assessment Form (Page 6 of 8) in pdf

Psychosocial Pain Assessment Form Page 6

Emotional

Pain affects our emotions. These questions will help us better understand your pain's impact upon you

emotionally.

1. Have you been troubled by feelings of:

Depression Yes ___ No___ Describe: __________________________________________________

Frustration/Anger Yes ___ No ___ Describe: ____________________________________________

Anxiety Yes___ No___ Describe: _____________________________________________________

Panic Attacks Yes___ No___ Describe: ________________________________________________

Mood Swings Yes___ No___ Describe: ________________________________________________

Difficulty Concentrating Yes___ No___ Describe: _______________________________________

Loss of Motivation Yes ___ No___ Describe: ___________________________________________

2. Do you ever see or hear things that others don't? Yes ___ No___

Describe:

________________________________________________________________________________

3. Are there any medical tests or procedures that frighten you? Yes ___ No___

Describe:

________________________________________________________________________________

4. Have you ever thought about hurting yourself or taking your life? Yes___ No___

Describe:

________________________________________________________________________________

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

Rating (0-10)

(0 = no concern, 10 = greatest concern)

Interviewer

Patient

Significant Other

Emotional issues

__________

_______________

Psychosocial Pain Assessment Form Page 6