"Pain Chart Template"

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PAIN CHART
Name___________________________________ DOB_____-_____-_____ Date_____-_____-_____
Please mark on the body diagrams all areas of pain, discomfort, or altered sensation, and use the
key below to identify quality of each.
A = ache
B = burning
E = electrical
S = stabbing
P = pins & needles
N = numb
O = other
Th = throbbing
PAIN CHART
Name___________________________________ DOB_____-_____-_____ Date_____-_____-_____
Please mark on the body diagrams all areas of pain, discomfort, or altered sensation, and use the
key below to identify quality of each.
A = ache
B = burning
E = electrical
S = stabbing
P = pins & needles
N = numb
O = other
Th = throbbing