"Body Pain Chart Template"
!["Body Pain Chart Template"](https://data.templateroller.com/pdf_docs_html/584/5849/584975/page_1_thumb.png ""Body Pain Chart Template"")
1Name:
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
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Most popular documents
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"Vsepr Theory (Molecular Shapes) Chart"
-
"Zappos Kid Shoe Size Chart"
-
DD Form 2813
-
DA Form 2062 "Hand Receipt/Annex Number"
-
DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
DD Form 1750 "Packing List"
-
AF Form 910 "Enlisted Performance Report (AB Thru Tsgt)"
-
DA Form 31 "Request and Authority for Leave"
-
DA Form 3595 "Record Fire Scorecard"
-
DD Form 2923 "Privacy Act Data Cover Sheet"
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- 2019 Tax Return Due Dates And Deadlines 2019 Tax Return Due Dates And Deadlines
- 2019 Tax Return Due Dates for Business Owners 2019 Tax Return Due Dates for Business Owners
- 2019 Tax Filing Deadlines for Individuals 2019 Tax Filing Deadlines for Individuals
- 2019 Payroll Tax Calendar for Employers 2019 Payroll Tax Calendar for Employers
- 10 Sample Interview Questions 10 Sample Interview Questions
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
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