Standardized Patient Portrayal of Pain
Event: ___________________________________
Patient’s Verbal Description of Pain
Intensity (circle number):
CASE: _______________________________
Quality of Pain
Location of Pain:
___ sharp/stabbing
1 2 3 4 5 6 7 8 9 10
___ dull/ache
If Variable intensity:
___ burning
Range from ___/10 to ___/10
Duration:
___ throbbing
__ Continuous
___ other:
__ Intermittent
(It would be helpful if you would
mark location on diagram on back
of this form.)
Radiation?
___ No
___ Yes
Where?
Details
Observable Behavior related to Pain (unrelated to exam)
Facial Expression:
Verbalization:
Body Language:
___ normal
___ sad/depressed
___ tearful/crying
___ anxious/fearful
___ agitated
___ grimacing/wincing
___ clenched teeth
Other:
___ moaning/groaning
___ difficulty talking
___ short comments
___ crying out
___ screaming
Other:
___ holds very still
___ frequent position changes
___ holds/protects painful area
___ assumes certain position:
describe:
Other:
Behavior during Exam or Due to Exam
Painful body region(s):____________________________________________
Palpation or Percussion results in:
___ No signs of pain/tenderness
___ Mild pain/tenderness slight wince/grimace, no verbalization
___ Moderate pain/tenderness moderate wince/grimace, with groan/moan
___ Severe pain/tenderness more dramatic grimace and loud verbalization (moan/groan/cry)
___ Other behavior: ___ tenses area examined; ___ withdraws/pulls away when examined
Painful body region(s):____________________________________________
Movement of body part results in:
___ No signs of pain/tenderness
___ Mild pain/tenderness slight wince/grimace, no verbalization
___ Moderate pain/tenderness moderate wince/grimace, with groan/moan
___ Severe pain/tenderness more dramatic grimace and loud verbalization (moan/groan/cry)
___ Withdraws/pulls away when examined
___ Other behavior: _________________________________________________________________
Courtesy of James Meyer, M.D.
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