"Body Pain Diagram Template"

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Download "Body Pain Diagram Template"

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Pain Diagram
Please mark the area of injury or discomfort on the chart below, using the appropriate
symbols:
Numbness
Pins & Needles
Burning
Aching
Stabbing
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
Please use the space below to describe your condition further if needed:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date: _________________ Signature: ___________________________________________
Pain Diagram
Please mark the area of injury or discomfort on the chart below, using the appropriate
symbols:
Numbness
Pins & Needles
Burning
Aching
Stabbing
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
⊗ ⊗ ⊗ ⊗
- - - - - -
o o o o o
^ ^ ^ ^ ^
x x x x
Please use the space below to describe your condition further if needed:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date: _________________ Signature: ___________________________________________