Labor and Delivery Pain Assessment Form
Please complete this form to help us assess and address your pain during labor and delivery. Your responses will guide your care and comfort.
Full Name
*
First Name
Last Name
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Current Pain Intensity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Pain Location
*
Please Select
Lower abdomen
Back
Pelvis
Legs
Other
Describe the Pain (e.g., sharp, dull, cramping)
How long have you been experiencing this pain?
Please Select
Less than 30 minutes
30 minutes to 1 hour
1 to 2 hours
More than 2 hours
What comfort measures or pain relief methods have you tried?
Breathing techniques
Movement/position change
Massage
Heat/cold therapy
Medication
Other
How effective were these methods?
Very effective
Somewhat effective
Not effective
Not tried yet
Additional Comments or Concerns
Submit Assessment
Should be Empty: