Geriatric Pain Assessment Form
Patient Name
Date
Assessor
Pain Location(s)
Pain Duration
Pain Frequency
Pain Description (e.g., sharp, dull, aching)
Pain Severity (0 = No pain, 10 = Worst possible pain)
Aggravating Factors
Relieving Factors
Impact on Sleep
Impact on Mobility
Impact on Mood
Current Pain Medication
Other Interventions Used
Additional Comments