Kaiser Permanente Pain Assessment Questionnaire free printable template

Chronic Pain Management Pain Assessment Questionnaire MR Name INFORMATION ABOUT YOUR PAIN PROBLEM 1. What is your main reason for coming to the pain clinic today 2. How long have you been in pain 3. Briefly describe how your pain started 4. Do you have any of the following with your pain Tingling/numbness in the hands/feet Weakness in the hands/feet Difficulty holding bladder or bowel movement Yes No 5. What triggers or makes your pain worse 6. What do you do to ease or relieve your pain...

How to fill out permanente assessment chronic form

How to fill out Kaiser Permanente Pain Assessment Questionnaire

1. Begin by entering your personal information at the top of the questionnaire, including your name, date of birth, and relevant contact information.
2. Read each question carefully and answer truthfully based on your pain experience.
3. For questions about pain intensity, use the provided scale (usually 0-10) to indicate your level of pain.
4. Describe the location of your pain by marking it on any diagrams provided in the questionnaire.
5. Indicate how your pain affects your daily activities and overall quality of life.
6. Provide information about any medications or treatments you are currently using to manage your pain.
7. Review your answers for completeness before submitting the questionnaire.

Who needs Kaiser Permanente Pain Assessment Questionnaire?

1. Individuals who experience chronic pain or discomfort.
2. Patients seeking treatment or management for pain-related conditions.
3. Those who are being evaluated for pain management programs.
4. Individuals who have had surgery or trauma that resulted in pain.
5. Anyone who needs to communicate their pain levels and impacts to healthcare providers.

People Also Ask about

What questionnaire measures pain?

The McGill Pain Questionnaire (MPQ) is a three-part pain assessment tool that measures several dimensions of the patient's pain experience (Fig. 222-4). The first part consists of an anatomic drawing of the human form on which the patient marks where his or her pain is located.

What is the best pain questionnaire?

Pain Assessment Scales Numerical Rating Scale (NRS) Visual Analog Scale (VAS) Defense and Veterans Pain Rating Scale (DVPRS) Adult Non-Verbal Pain Scale (NVPS) Pain Assessment in Advanced Dementia Scale (PAINAD) Behavioral Pain Scale (BPS) Critical-Care Observation Tool (CPOT)

What questioning do you fill in the pain assessment form?

Where are you feeling pain? When did the pain start? How long have you been in pain? Is the pain constant or intermittent?

What assessment tool is used to evaluate pain?

Numerical Rating Pain Scale The Numerical Rating Scale (NRS) is designed for anyone over age 9. It is one of the most commonly used pain scales in health care. To use it, you just say the number that best matches the level of pain you are feeling; you can also place a mark on the scale itself.

What is the most common pain questionnaire?

McGill pain questionnaire (MPQ) This is one of the most widely used multidimensional pain scales. It appears in questionnaire form, and assesses a person's pain based on the words they use to describe their pain.

What is the gold standard for pain questionnaire?

A Numerical Rating Scale (NRS) ranging from 0 to 10 (0, no pain; 10, maximum pain), which is based on a patient's self-report, is the gold standard for pain evaluation in patients who can communicate their pain intensity.

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What is Kaiser Permanente Pain Assessment Questionnaire?

The Kaiser Permanente Pain Assessment Questionnaire is a tool used to collect detailed information regarding a patient's pain experience, including the intensity, location, and nature of their pain, as well as any associated symptoms.

Who is required to file Kaiser Permanente Pain Assessment Questionnaire?

Patients who are experiencing pain and are enrolled in the Kaiser Permanente health system are typically required to fill out the Pain Assessment Questionnaire as part of their assessment and treatment plan.

How to fill out Kaiser Permanente Pain Assessment Questionnaire?

To fill out the Kaiser Permanente Pain Assessment Questionnaire, patients should carefully read the instructions, provide detailed responses regarding their pain experiences, and provide any relevant medical history or related symptoms as instructed.

What is the purpose of Kaiser Permanente Pain Assessment Questionnaire?

The purpose of the Kaiser Permanente Pain Assessment Questionnaire is to facilitate effective communication between patients and healthcare providers about pain management needs and to guide treatment options based on the reported information.

What information must be reported on Kaiser Permanente Pain Assessment Questionnaire?

Patients must report information such as the intensity and location of their pain, duration, triggers, pain management strategies used, and any other symptoms or medical history pertinent to their pain condition.