Home Health Care Pain Assessment Tool
Patient Name
Date of Assessment
Pain Location
Pain Description
Pain Intensity (0 = No Pain, 10 = Worst Possible Pain)
0
1
2
3
4
5
6
7
8
9
10
Pain Type
Acute
Chronic
Breakthrough
Other
Pain Pattern
Constant
Intermittent
Worse at Night
Other
Factors that Increase Pain
Factors that Relieve Pain
Current Pain Management (medications/non-medications)
Effectiveness of Pain Management