Onset:

Duration:

Quality: Prick / Dull ache / Burning / Throbbing / Pulling / Sharp shooting

Rhythm: Constant / Intermittent

Manner Of Expressing Pain: Verbal / Facial expression

Aggravating Factors:

Releiving Factors:

Effects Of Pain On Physical Activity:

Getting in/out of bed, Getting in/out of chair, Standing/Walking, Walking up/down stairs, Work
activities, Other activities (sitting, cooking, dressing, cleaning, lifting, etc.)

Accompanying symptoms: Sleep: Appetite:

Irritability:

Medical / Surgical / Occupational H/O :

Personal History:

a. Smoking: Yes / No Since:_____________

b. Tobacco chewing: Yes / No Since:_____________

c. Alcohol consumption: Yes / No Since:_____________

d. Physical / Recreational activity:

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Family History:

Socio-economic Status: Poor / Fair / Good

Investigation:

Vital Signs:

Heart Rate: /min Respiratory Rate: /min Blood Pressure: /

mmHg Temperature: .C

General Examination:
General Body Built:

Posture:

Gait:

Local Examination:

Temperature:

Swelling: ______________________________ Soft / Firm / Hard Pitting / Nonpitting

Tenderness:

Spasm:

Crepitus:

Attitude of the limbs / body part:

Any other findings:(e.g.,Trophical changes / Scar / Wound):