Pain Template - Home Health Patient Education

Select as applicable
- Pain Information
- Reasons for Pain
- Pain Site
- Pain Exacerbation Factors
- Pain Management
- Pain Medications
- Neuropathy
- Additional Information
No Pain Information
- Patient has no complaint of pain.
- Pain is not a concern for the patient any day.
- Patient takes OTC pain medications, only as needed.
Pain grade if patient complains of occasional low grade pain (number only)
Pain type
- continuous
- on and off
Pain grade
- low grade
- moderate grade
- severe grade
Reason for pain
- gout ;
- multiple sclerosis ;
- rheumatoid arthritis ;
- neuropathy ;
- osteoarthritis ;
Other reasons for pain
Pain site
- weight bearing joints ;
- diffuse body ;
- small joints in extremities ;
- upper back ;
- lower back ;
- wound site ;
Additional pain site
Pain exacerbation factors
- weight bearing ;
- ambulation ;
- inflamed joints ;
- diffuse muscle spasms ;
- contractures ;
Other pain exacerbation factors
Pain Management
- Patient takes pain medications, only on an as needed basis.
- Patient does not want to take any pain medications.
- Patient would consider only alternative pain management strategies for pain control.
- Patient has no prescription pain medications, but takes OTC pain medications.
- Patient is on multiple medications for pain management.
Pain Medications
- Tylenol ;
- Tramadol ;
- Percocet ;
- Norco ;
- Tylenol # 3 ;
- Fentanyl patch every 72 hours ;
- Oxycontin ;
- Hydrocodone ;
- Ibuprofen ;
- Meloxicam ;
- Celebrex ;
- Diclofenac ;
- Naproxen ;
- Prednisone ;
- Hydrocortisone ;
Additional Pain Medications
Recent changes with pain medications
- no changes happened with pain medications
- dose changes happened with pain medications
- new pain medications are added
- narcotic pain medications were discontinued
- change happened in pain medication schedule to as needed basis
Side Effects of Pain Medications
- none ;
- nausea ;
- vomiting ;
- constipation ;
- dizziness ;
- confusion ;
- difficulty breathing ;
Additional Side Effects
Please specify recent pain variation on a scale of 0-10 (number only)
Pain Level Today on a scale of 0-10 (number only)
Neuropathy
- Nerve pain in the extremities has been a recent complaint.
- Neuropathy has been a chronic complaint.
- Patient complains of nerve pain in both lower extremities.
- Patient complains of nerve pain in all the extremities.
- Patient has been started on medication to manage the neuropathy in the extremities.
- Patient continues on antineuropathy medication for control of nerve pain reported.
Neuropathy Exacerbation Factors
- poor control of blood sugars ;
- relapse of multiple sclerosis ;
- progression of disc degeneration ;
- pinched nerves in the spine ;
- peripheral vascular disease ;
- poor blood supply to the distal extremities ;
- chemotherapy ;
- chronic smoking ;
Other factors for exacerbation of neuropathy
Antineuropathy medications (name only)
Pain control response
- well controlled
- moderately controlled
- poorly controlled
Goals for Pain Management
- Patient wants pain to be completely resolved and managed at 0 on a scale of 0 – 10.
- Patient wants pain to be managed between 0 – 5, with no exacerbation beyond 6, on a scale of 0 – 10.
- Patient wants to have the pain managed at a max of 2 – 3 on a scale of 0 – 10.
- Patient wants to prevent any acute exacerbation of pain from happening.
- Pain is well-controlled and patient has no goals with regards to pain management.
Additional Information-Pain

Pain Status Template