"Body Pain Chart Template"

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Download "Body Pain Chart Template"

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Name:
Date:
Pain Chart
Using the symbols below, mark on the body the areas where you feel that particular sensation.
Numbness
Pins & Needles
Burning
Aching
Sharp/Stabbing
//////
+++++
00000
XXXXX
*******
PLEASE CIRCLE YOUR LEVEL OF PAIN:
(1 = Minimal Pain; 10= Worst Pain Imaginable)
PAIN CURRENTLY
1
2
3
4
5
6
7
8
9
10
PAIN AT ITS WORST
1
2
3
4
5
6
7
8
9
10
PAIN TYPICALLY
1
2
3
4
5
6
7
8
9
10
Name:
Date:
Pain Chart
Using the symbols below, mark on the body the areas where you feel that particular sensation.
Numbness
Pins & Needles
Burning
Aching
Sharp/Stabbing
//////
+++++
00000
XXXXX
*******
PLEASE CIRCLE YOUR LEVEL OF PAIN:
(1 = Minimal Pain; 10= Worst Pain Imaginable)
PAIN CURRENTLY
1
2
3
4
5
6
7
8
9
10
PAIN AT ITS WORST
1
2
3
4
5
6
7
8
9
10
PAIN TYPICALLY
1
2
3
4
5
6
7
8
9
10