Name of Service User: D.O.B: Male / Female (Circle) Establishment: GP Name: Date: Time: Assessment Number: Known Pain History (E.g. Relevant history, Environmental factors (E.g. room temperature, Arthritis, joint pain, hip replacement) noise, seating) Facial expression (E.g. grimacing, wincing, frowning) Body Movement (E.g. altered gait, pacing, rocking, repetitive movement) (E.g. Sighing, grunting, groaning, aggression) Verbalisation / Vocalisation Interpersonal interactions (E.g. Aggression, withdrawal, resisting) Changes in activity patterns (E.g. walking with purpose, altered sleep, altered rest pattern) Mental Status (Crying, distress, irritability) Physical Changes (E.g. skin tear, pressure area, stiffness in joints, flushed or pale face,)
Name of Service User: D.O.B: Male / Female (Circle) Establishment: GP Name: Date: Time: Assessment Number: Known Pain History (E.g. Relevant history, Arthritis, joint pain, hip replacement) Environmental factors (E.g. room temperature, noise, seating) Facial expression (E.g. grimacing, wincing, frowning) Body Movement (E.g. altered gait, pacing, rocking, repetitive movement) Verbalisation / Vocalisation (E.g. Sighing, grunting, groaning, aggression) Interpersonal interactions (E.g. Aggression, withdrawal, resisting) Changes in activity patterns (E.g. walking with purpose, altered sleep, altered rest pattern) Mental Status (Crying, distress, irritability) Physical Changes (E.g. skin tear, pressure area, stiffness in joints, flushed or pale face,)
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