Sample Pre-visit Questionnaire Pain Management
Initial Pain Assessment Tool Patient's name:_____________________________________________________________ Date:________________ Age:_____________ Room:______________ Diagnosis:_________________________________________________ Physician:___________________________________________ Nurse:_____________________________________ 1.
Location: Patient or nurse marks drawing
2.
Intensity: Patient rates the pain. Scale used: __________________________________________________ Present:__________________________________________________ Worst pain gets:__________________________________________ Best pain gets:___________________________________________ Acceptable level of pain:_________________________________
3.
Quality: (Use patient's own words, e.g., prick, ache, burn, throb, pull, sharp)___________________________ ______________________________________________________________________________________
4.
Onset, duration, variations, rhythms:________________________________________________________ ______________________________________________________________________________________
5.
Manner of expressing pain: _______________________________________________________________
6.
What relieves the pain?___________________________________________________________________
7.
What causes or increases the pain?_________________________________________________________
8.
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, suicidal, crying )_________________________________________________________ Concentration ____________________________________________________________________________ Other ___________________________________________________________________________________
9.
Other comments:__________________________________________________________________________
10. Plan:____________________________________________________________________________________ _________________________________________________________________________________________ © From McCaffery M, Beebe A. Pain: A Clinical Manual for Nursing Practice. St Louis: The C.V. Mosby Co.;1989. Reprinted with Permission
Patient Name: ________________________________________________________ Date: ______________________
0-10 Numeric Pain Intensity Scale*
0 No pain
1
2
3
4
5 Moderate pain
6
7
8
9
10 Worst possible pain
*If used as a graphic rating scale, a 10-cm baseline is recommended. From: Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032; February 1992. Agency for Healthcare Research & Quality, Rockville, MD; pages 116-117.
A7012-AS-2
PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer)
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9. Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
FOR OFFICE CODING
0
+ ______ + ______ + ______ =Total Score: ______
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
Q Quality of Life Scale S
Measure of Funcction for Peoople with Paain
0
Stay in bed all day d Feel hopeless and a helplesss about life e
1
Stay in bed at le east half the day Have e no contacct with outsiide world
2
Get out o of bed but b don’t ge et dressed Stay home all day d
3
Get dressed in the mornin ng Minim mal activitie es at home Conttact with frie ends via ph hone, email
4
Do simple s chore es around the t house Minim mal activitie es outside of o home two o days a we eek
5
Strug ggle but fulffill daily hom me responssibilities No outside o activvity Not able a to work/volunteerr
6
Workk/volunteer limited hou urs Take e part in lim mited social activities on weekends
7
Workk/volunteer for a few hours h daily Can be active at a least five hours a da ay Can make planss to do simple activitie es on weekkends
8
Workk/volunteer for at leastt six hours daily d Have e energy to make plan ns for one evening e soccial activvity during th he week Activve on weeke ends
9
Workk/volunteer//be active eight e hours daily Take e part in fam mily life Outsside social activities a lim mited
No on-functioning
10
Normal Quality off Life
Go to o work/volu unteer each h day Norm mal daily acctivities eacch day Have e a social liffe outside of o work Take e an active part in family life
The scale is meant to h help individuaals measure aactivity levels.. It is recognizzed that hom memakers, parrents, and retireees often don’t work outside the home,, but activity can still be m measured in th he amount off time one is able to “work” aat fulfilling daaily responsibilities, be thatt in a paid job b, as a volunteer, or within n the home.
Pain Disability Index Name ______________________________________________________________ Date _____________________ Pain disability index: The rating scales below are designed to measure the degree to which aspects of your life are disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst. For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain. Family/Home Responsibilities: This category refers to activities of the home or family. It includes chores or duties performed around the house (eg, yard work) and errands or favors for other family members (eg, driving the children to school). No disability 0 1 2 3 4 5 6 7 8 9 10 Recreation: This category includes hobbies, sports, and other similar leisure time activities.
Worst disability
No disability 0 1 2 3 4 5 6 7 8 9 10 Worst disability Social Activity: This category refers to activities that involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. No disability 0 1 2 3 4 5 6 7 8 9 10 Worst disability Occupation: This category refers to activities that are a part of or directly related to one’s job. This includes nonpaying jobs as well, such as that of a housewife or volunteer worker. No disability 0 1 2 3 4 5 6 7 8 9 10 Sexual Behavior: This category refers to the frequency and quality of one’s sex life.
Worst disability
No disability 0 1 2 3 4 5 6 7 8 9 10 Worst disability Self‐Care: this category includes activities that involve personal maintenance and independent daily living (eg, taking a shower, driving, getting dressed, etc.) No disability 0 1 2 3 4 5 6 7 8 9 10 Worst disability Life‐Support Activity: This category refers to basic life‐supporting behaviors such as eating, sleeping, and breathing. No disability 0 1 2 3 4 5 6 7 8 9 10
Pollard CA. Percept Mot Skills. 1984;59(3):974‐981.
Worst disability
Patient Pain History Patient Name ___________________________________ Date ________________________________ Current Diagnosis(es) __________________________________________________________________ Previous Condition(s) __________________________________________________________________ Please list ALL CURRENT medications taken for your pain: Medication Name
Dates Taken From To
Dosage Indication Effect If you need more space, please use the bottom of this sheet or the back of this page.
Side Effects
Please list ALL PREVIOUS medications taken for your pain: Medication Name
Dosage
Dates Taken From To
Indication
Effect
If you need more space, please use the bottom of this sheet or the back of this page.
Side Effects
Please list all CURRENT and PREVIOUS pharmacies: _____________________________________________________________________________________ _____________________________________________________________________________________ If you need more space, please use the bottom of this sheet or the back of this page. Please check all previously or currently used methods of pain management: [ ]Acupuncture [ ]Biofeedback [ ]Homeopathy
[ ]Massage [ ]Hypnosis [ ]Naturopathy
[ ]Meditation [ ]Chiropractor [ ]Physical Therapy
[ ]Visual Imagery [ ]Acupressure [ ]Exercise
[ ]Herbal Medication [ ]Nutritional Support
Please explain _________________________________________________________________________ _____________________________________________________________________________________
Information for the Patient Tips on Talking about Pain With Your healthcare Provider Pain assessment is critical to effective pain management. The following approach to assessing your pain—focusing on words to describe intensity, location, duration, and aggravating and alleviating factors—will better help your healthcare provider develop effective treatment strategies. Words to Describe Pain Aching Stabbing Tender Tiring Numb Dull Crampy
Throbbing Gnawing Burning Penetrating Miserable Radiating Deep
Shooting Sharp Exhausting Nagging Unbearable Squeezing Pressure
Intensity (0 to 10) If 0 is no pain and 10 is the worst possible pain, what is your pain now? In the last 24 hours? Location Where is your pain? Duration Is the pain always there? Or does the pain come and go (breakthrough pain)? Do you have both types of pain? Aggravating and alleviating factors What makes your pain better? What makes your pain worse? How does pain affect: Sleep Appetite
Energy Activity
Relationships Mood
Are you experiencing any other symptoms? Nausea/vomiting Constipation
Itching Sleepiness/confusion
Urinary retention Weakness
WILDA Pain Assessment Guide used with permission from Regina Fink at the University of Colorado Health Sciences Center.
Managing Insomnia: Good sleep Habits Promote Sleep Nothing is more frustrating that not being able to fall asleep and stay asleep. It is not comfortable for a patient with pain to toss and turn all night and watch the clock and the window for signs of morning. Even worse, pain can aggravate poor sleep, and a poor night’s sleep can aggravate pain. However, there are things you can do— Simple things that can help you with insomnia. It may take a week or two before you experience relief, but don’t get discouraged. Follow these suggestions carefully. Get rid of any habits that might contribute to sleep problems •
• • • •
•
People use caffeine to stay awake. Don’t drink caffeinated beverages, especially in the late afternoon or evening. Coffee, tea, and soft drinks all contain caffeine. But it can be found in other things, too—in chocolate and in cocoa, for example. Even some prescription and non‐prescription drugs contain caffeine. Some of the medicines that contain caffeine include: - Allergy, anxiety, depression, epilepsy, nausea, and thyroid medicines - Cold, cough, and decongestants (nose and chest) medicines - Diuretics - Painkillers Tobacco products are bad for your health at any time. But nicotine is a stimulant that also interferes with your ability to sleep, so avoid it, especially at night. Alcohol can also interfere with sleep, so do not drink it before bedtime. Alcohol may help you fall asleep because it slows brain activity, but it has a “rebound” effect and will awaken you later in the night. Don’t take naps, if possible. This will help ensure that by bedtime you will be sleepy. If a nap is unavoidable, try to make do with on that lasts less than an hour. Don’t eat a heavy meal before bedtime. A digestive system that has been activated can keep you awake; it can also cause indigestion and acid reflux. A light snack will ensure that and empty stomach won’t wake you. Dairy products like milk contain tryptophan, a substance that acts as a natural sleep inducer. However, drinking excessively before bedtime can interfere with your sleep by requiring excessive trips to the bathroom. Regular exercise is not only good for your health in general; it’s also a great sleep aid. But timing is critical. Don’t schedule a workout 3 or 4 hours before bedtime. Morning or early afternoon exercise regimens are best.
Crate a comfortable sleep environment • • • •
Your bedroom temperature should be on the cool side, but not cold. A hot room can be uncomfortable. Your room should be dark and quiet. To clock out light, get a night shade or use a sleep mask. If noise is a problem, either wear earplugs or get a “white noise” machine to block sound. Be sure your mattress is comfortable. An uncomfortable mattress can affect your sleep considerably. If necessary, buy a new mattress. Experiment with different levels of firmness to get the one best suited to your needs.
Cultivate good sleep habits • • • • •
Don’t go to bed until you’re sleepy. If you’re not ready to fall asleep, then stay up until you are. You can’t force yourself to fall asleep. Calm your mind before you attempt to sleep. Don’t worry about things in bed. Before retiring, listen to soothing music, read something relaxing, do meditation exercises. Don’t use the bed for anything except sleeping. Don’t eat, watch television, balance your checkbook, make phone calls or lists, or do anything else in bed (sex is fine) except sleep. That’s what beds are for. Once in bed, if you’re not asleep within approximately 20 minutes or so, get up and leave the bedroom. Don’t return until you’re sleepy. Try to get up and go to bed at the same time, even on weekends. Getting your body used to a regular sleep schedule will help with your sleep cycle.
Frequently Asked Questions about Sustained‐Release Opioid Treatment 1. How can I best manage my chronic pain? Pain is not something you must accept – no matter how severe. You can take an active part in your care by regularly reviewing your pain symptoms with your healthcare provider. Be sure to fill in your pain diary every day, and bring it with you to every office visit. Take all medications as directed by your healthcare provider. And take ONLY those that he or she has prescribed or recommended – including over‐the‐counter medications. 2. What if I still have moments of pain? Even though you have taken a long‐acting medication, there still may be times when you feel some pain. This pain, called “breakthrough pain,” can be caused by changes in your condition, or an activity such as climbing stairs, gardening, or housekeeping. Your healthcare provider may choose to prescribe an additional immediate‐release medication – called a “rescue dose” or breakthrough medication” – to take ONLY when you have breakthrough pain. 3. Are there any side effects? Constipation is a common side effect of opioids. Discuss preventive steps with your healthcare provider. Other common side effects include nausea, drowsiness, and itching. 4. Will I become addicted? The medication you are taking is for pain relief. However there is a risk of abuse or addiction with any drug. If you have abused drugs in the past, you have a higher chance of developing an abuse problem or addiction. Discuss your concerns with your healthcare provider. Note: addiction is not the same as physical dependence. Physical dependence occurs with many medications and means that on discontinuation of the drug, you might have withdrawal symptoms. Stopping any medication should be done in consultation with your healthcare provider.
Opioid Risk Tool Clinician Form (includes point values to determine scoring total)
Mark each box that applies. 1. Family History of Substance Abuse:
Female
Male
Alcohol
1
3
Illegal Drugs
2
3
Prescription Drugs
4
4
Alcohol
3
3
Illegal Drugs
4
4
Prescription Drugs
5
5
3. Age (mark box if between 16-45)
1
1
4. History of Preadolescent Sexual Abuse
3
0
5. Psychological Disease Attention Deficit Disorder, Obsessive-Compulsive Disorder, Bipolar, Schizophrenia
2
2
1
1
2. Personal History of Substance Abuse:
Depression
Scoring Totals
Published with the permission of Lynn R. Webster, MD (2005)
Opioid Risk Tool Patient Form
Mark each box that applies. 1. Family History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs
2. Personal History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs
3. Age (mark box if between 16-45)
4. History of Preadolescent Sexual Abuse
5. Psychological Disease Attention Deficit Disorder, Obsessive-Compulsive Disorder, Bipolar, Schizophrenia Depression
Published with the permission of Lynn R. Webster, MD (2005)
Female
Male
