B2. Initial Pain Assessment Tool

                                           Date:________________

Patient's name:_______________________ Age:________ Room:_______

Diagnosis:____________________________ Physician:_______________
                                           Nurse:_______________

   I. Location: Patient or nurse marks drawing



  II. Intensity: Patient rates the pain. Scale used: ___________
      Present:__________________________________________________
      Worst pain gets:__________________________________________
      Best pain gets:___________________________________________
      Acceptable level of pain:_________________________________

 III. Quality: (Use patient's own words, e.g., prick, ache, burn,
      throb, pull, sharp)
      __________________________________________________________

  IV. Onset, duration, variations, rhythms:_____________________
      __________________________________________________________

   V. Manner of expressing pain:________________________________
   
  VI. What relieves the pain?___________________________________
   
 VII. What causes or increases the pain?________________________
   
VIII. Effects of pain: (Note decreased function, decreased quality
      of life.)
      Accompanying symptoms (e.g., nausea)_______________________
      Sleep______________________________________________________
      Appetite___________________________________________________
      Physical activity__________________________________________
      Relationship with others (e.g., irritability)______________
      Emotions (e.g., anger, suididal, crying)___________________
      Concentration______________________________________________
      Other______________________________________________________
   
  IX. Other comments:___________________________________________
   
   X. Plan:_____________________________________________________
      __________________________________________________________

Note: May be duplicated and used in clinical practice
Source: McCaffery and Beebe, 1989. Used with permission.