"Body Pain Diagram Template"

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Download "Body Pain Diagram Template"

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PAIN   D IAGRAM  
 
NAME   _ ______________________________________________   D ATE   _ __________________  
 
How   l ong   h ave   y ou   h ad   p ain   ?   _ ________years     _ _________months   _ __________weeks  
 
On   t he   p ain   d iagram   b elow,   p lease   i ndicate   w here   y ou   a re   e xperiencing   p ain   o r   o ther  
symptoms,   r ight   n ow.      
List   t he   M AIN   r eason   y ou   a re   s eeing   t he   h ealthcare   p rovider   f or   t oday:  
 
 
A   =   A CHES             B   =   B URNING             N   =   N UMBNESS  
P   =   P INS   &   N EEDLES               S   =   S TABBING  
     
O   =   O THER               P lease   m ark   a n   X   a t   t he   a rea   y ou   a re   h aving   p ain.  
 
PAIN   D IAGRAM  
 
NAME   _ ______________________________________________   D ATE   _ __________________  
 
How   l ong   h ave   y ou   h ad   p ain   ?   _ ________years     _ _________months   _ __________weeks  
 
On   t he   p ain   d iagram   b elow,   p lease   i ndicate   w here   y ou   a re   e xperiencing   p ain   o r   o ther  
symptoms,   r ight   n ow.      
List   t he   M AIN   r eason   y ou   a re   s eeing   t he   h ealthcare   p rovider   f or   t oday:  
 
 
A   =   A CHES             B   =   B URNING             N   =   N UMBNESS  
P   =   P INS   &   N EEDLES               S   =   S TABBING  
     
O   =   O THER               P lease   m ark   a n   X   a t   t he   a rea   y ou   a re   h aving   p ain.