"Body Pain Diagram and Pain Rating Sheet"

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Pain Diagram and Pain Rating
Name:
Date: /
/
INSTRUCTIONS: Please use the diagram below to indicate the symptoms you have
experienced over the past 24 hours. Use the key to indicate the type of symptoms.
KEY:
Pins and Needles = 000000
Stabbing
= / / / / / /
Burning
= xxxxxx
Deep Ache = zzzzzz
Please rate your current level of pain on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Please rate your worst level of pain in the last 24 hours on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Please rate your best level of pain in the last 24 hours on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Version Feb08
Pain Diagram and Pain Rating
Name:
Date: /
/
INSTRUCTIONS: Please use the diagram below to indicate the symptoms you have
experienced over the past 24 hours. Use the key to indicate the type of symptoms.
KEY:
Pins and Needles = 000000
Stabbing
= / / / / / /
Burning
= xxxxxx
Deep Ache = zzzzzz
Please rate your current level of pain on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Please rate your worst level of pain in the last 24 hours on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Please rate your best level of pain in the last 24 hours on the following scale (check one):
0
1
2
3
4
5
6
7
8
9
10
(no pain)
(worst imaginable pain)
Version Feb08