Registered Nurses´ Association of Ontario
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Tools for Assessment of Pain in Adults
SAMPLE 6 - Calgary Interagency Pain Assessment Tool
PART I – PATIENT REPORT
1. Please mark the area of pain on the drawing. If you have more than one pain, label them A, B, C, etc.
2. How would you rate your overall pain?
(Scale used: 
0 – 10 scale 0 – 5 scale )
At present time _______
At its least _______
At its worst _______
Acceptable _______
3. How and when did your pain begin?
______________________
4. Check the words that best describe the kind of pain you have.
- Dull ache
- Pins and needles
- Burning
- Sharp
- Stabbing
- Internal
- Cramping
- Throbbing
- External
- Other: ____________
5. How long does the pain usually last?
- Seconds
- Minutes
- Hours
- Constant
6. What makes the pain worse?
- Walking
- Moving
- Eating
- Other: ____________
Is your pain worse at a particular time of day?
When?
__________________________
8. What makes the pain better?
- Walking
- Moving
- Eating
- Other: ____________
9. What pain medications are you presently taking?
__________________________
10. What medications have helped to control
your pain?
__________________________
11. What medications have not helped?
__________________________
12. Has the pain or treatment produced any other effects?
- Nausea
- Unclear thinking
- Dizziness
- Anxiety
- Disturbed sleep
- Drowsiness
- Constipation
- Diarrhea
- Changes in mood
- Loss of appetite
- Other: ____________
PART II – PATIENT ASSESSMENT
(Please incorporate this data into the patient/family care plan)
Assess how the pain affects the patient's life. (eg. finances, job, family relationships)
________________________________________________________________________________________________
Assess how the pain affects the patient's daily activities. (eg. bathing, activity, sleeping, eating, walking)
________________________________________________________________________________________________
Other information relevant to this pain problem.
(eg. objective assessment, affect, guarding, grimacing, vital signs)
________________________________________________________________________________________________
Date:____________________
Signature:__________________
PART III – DISCHARGE OR REFERRAL
Complete discharge summary including:
- Pain history
- Course of treatment
- Relevant pain consultation
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date:____________________
Signature:__________________
Reprinted with permission of Calgary Health Region.
Reference: Huber, S., Feser, L. & Hughes, d. (1999). A collaborative approach to pain assessment.
Canadian Nurse, 95(8), 22-26.
