Pain Assessment Form
- Patient Name: Luke Carlton
- Age: 49
- Form Completed By: Dr. Joe Wilson
Patient was in some distress today when he came in. He says that the pain is negatively affecting his performance at work, as some days he is barely able to stand.
What is the location of the pain?
Lower back
On a scale of 1 – 10, how does the patient rate the intensity of the pain?
At best: 3
At worst: 8
Right now: 6
How often does the pain occur?
Patient reports that the pain started out as intermittent several years ago. However, recently the pain became constant.
What is the nature/quality of the pain?
Patient reports constant throbbing throughout the day. In addition, when the patient stands up, he feels a sharp, shooting pain travel up his back.
What causes the pain?
Patient works as a mechanic. He says that he spends six to eight hours a day bent over cars.
What does the patient do to relieve the pain?
Patient uses a heating pad for several hours each day. He also takes at least four aspirin pills a day.
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