Patient Medical History Form

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PATIENT MEDICAL HISTORY
PAIN INTENSITY SCALE
PAIN LOCATION BODY
DIAGRAMS
10
Pain as bad as it could be
9
Excruciating
8
7
Severe
6
5
Moderate
4
3
Mild
2
Slight
1
0
No Pain
1.
Circle the point on the pain intensity scale at the point that best describes your pain at the present time.
2.
Draw the location of your pain on the body diagrams above.
3.
Please describe the details of your injury, including the date of injury and any treatment of the injury:
Form 2
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL
-8/2016

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