Emergency Room Pain Assessment Form
Patient Name
Date & Time
Chief Complaint
Pain Location (mark all that apply)
Head
Chest
Abdomen
Back
Arm
Leg
Other
Describe the Pain (quality, character, etc.)
Onset (when did it start?)
Duration (how long does it last?)
Frequency (how often?)
Aggravating Factors
Relieving Factors
Pain Intensity (0 = No Pain, 10 = Worst Possible Pain)
0
1
2
3
4
5
6
7
8
9
10
Associated Symptoms
Medications Taken
Nurse Signature
Time