"Verbal Pain Description Chart Template"

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Verbal Pain Description Chart (VDS)
Patient’s Name: ________________________________________________________________
Reference Record #: ____________________________________________________________
Tel: (home) ________________________
(Mobile) ___________________________________
Date of Birth: ____________________________
Gender:
Male
Female
Select your pain level from the choices below:
The most intense pain imaginable ___________________________________
Very severe pain ________________________________________________
Severe pain ____________________________________________________
Moderate pain __________________________________________________
Mild pain ______________________________________________________
Slight pain _____________________________________________________
No pain ________________________________________________________
Other comments / Notes / Details:
www.FreePrintableMedicalForms.com
Verbal Pain Description Chart (VDS)
Patient’s Name: ________________________________________________________________
Reference Record #: ____________________________________________________________
Tel: (home) ________________________
(Mobile) ___________________________________
Date of Birth: ____________________________
Gender:
Male
Female
Select your pain level from the choices below:
The most intense pain imaginable ___________________________________
Very severe pain ________________________________________________
Severe pain ____________________________________________________
Moderate pain __________________________________________________
Mild pain ______________________________________________________
Slight pain _____________________________________________________
No pain ________________________________________________________
Other comments / Notes / Details:
www.FreePrintableMedicalForms.com