Non-Verbal Patient Pain Assessment Form

Patient Name Date Assessor Name Location/Unit

Pain Indicators

Indicator	Absent	Mild	Severe
Facial Expression
Vocalization (e.g., moaning, crying)
Body Movement
Guarding/Protective Movements
Physiological Indicators (e.g., pulse, BP)

Pain Score (0 = No Pain, 10 = Worst Possible)

Pain Location (describe or draw, if possible)

Comments/Notes