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

Psychosocial Pain Assessment Form Page 8

PSYCHOSOCIAL PAIN ASSESSMENT FORM

Coping

continued

7. Some people use other chemicals to help them cope. Which of these do you use?

Tobacco? Yes ____ No ____ Describe:_________________________________________________

Alcohol? Yes ____ No ____ Describe:_________________________________________________

Recreational Drugs? Yes ____ No ____ Describe:_________________________________________

Have you ever tried to stop using these? Yes ____ No ____ Describe:_________________________

Do you worry about your usage of these? Yes ____ No ____ Describe:________________________

Has your family worried about your usage of these? Yes ____ No ____ Describe:________________

8. What changes do you expect in your future?

Describe: ________________________________________________________________________

Overall, how satisfied are you with your present quality of life?

Describe: _______________________________________________________________________

10. Please rate your overall level of concern regarding your ability to cope or manage your pain.

Rating (0-10)

(0= no concern, 10 = greatest concern)

Interviewer

Patient

Significant Other

Coping

__________

_______

_______________

Developed by: Shirley-Otis-Green, MSW, LCSW

City of Hope National Medical Center

Publications

Otis-Green, S. (2006). Psychosocial Pain Assessment Form. In Dow (Ed.), Nursing Care of

Women with Cancer. St. Louis, MO: Elsevier Mosby, 556-561.

Otis-Green, S. (2005). Psychosocial Pain Assessment Form. In Kuebler, Davis, Moore (Eds.),

Palliative Practices: An Interdisciplinary Approach. St. Louis, MO: Elsevier Mosby, 462-467.

The Psychosocial Pain Assessment Form can be found on the

City of Hope Pain/Palliative Resource Center website at

(English)

(Spanish - Adults)

(Spanish - Children/Adolescents)

Psychosocial Pain Assessment Form Page 8