Pain Diagram and Rating

Please mark on the diagram the location of the pain.

Key:
/// stabbing
+++ aching
xxx burning
000 pins & needles
= = = numbness
### other/general

PAIN LEVEL: 0 1 2 3 4 5 6 7 8 9 10
No pain worst pain
(Check the worst & best it’s been and circle your current pain level)

What date (roughly) did the symptoms begin? _____________________________________

Did your pain begin ___Gradually? ___Suddenly? ___By Injury? Explain: ______________
___________________________________________________________________________
Have you had this or similar problems before? ___YES ___NO If yes, when? ____________
Have you had previous care that was effective _____________________________________
Or not effective _____________________________________________________________
What aggravates your symptoms? __Sitting, __Rise from Sitting, __Standing,
__Lying Down, __Lifting, __Overhead Activity, __Bending, __Walking, __Running, __Stairs,
__Squatting, __Coughing/Sneezing Other:________________________________________________
What eases your symptoms? __Ice, __Heat, __ Rest, __Changing Positions, __Sitting __Standing,
__Walking, __Lying down
Other__________________________________
Do you have a history of previous injuries? (Fractures, broken bones, sprains, strains, MVA)__________
______________________________________________________________________________________
Do you have a history of previous surgeries, scars? __________________________________________
______________________________________________________________________________________