Body Pain Location Chart
ADVERTISEMENT
1WOODWARD CHIROPRACTIC
Accident and Injury Care
MARK WOODWARD, D.C.
1048 US 31-W Bypass
Bowling Green, KY 42101
(270) 781-5644/ Fax (270) 781-4401
PAIN CHART
SHOW AREA(S) OF PAIN OR UNUSUAL FEELING
How long have you had your symptoms for current episode? ______ months ______ weeks
Mark the areas on this body where you feel the described sensations.
Use the appropriate symbols.
Mark areas of radiation.
Include all affected areas.
Numbness
Pins & Needles
Burning
Aching
Stabbing/Sharp
----------------
OOOOOOOOOO
XXXXXX
*******
/ / / / / / / / / / / / / /
----------------
OOOOOOOOOO
XXXXXX
*******
/ / / / / / / / / / / / / /
----------------
OOOOOOOOOO
XXXXXX
*******
/ / / / / / / / / / / / / /
Please mark on the pain scale from 0-10 the pain you feel with this condition. 10 being the worst pain you have felt
with this condition.
Neck-Shoulder-Arm Pain
On a scale of 0-10, I rate my
discomfort as follows:
___________________________
0
10
No Pain
Severe Pain
Mid Back Pain
On a scale of 0-10, I rate my
discomfort as follows:
___________________________
0
10
No Pain
Severe Pain
Low Back & Leg Pain
On a scale of 0-10, I rate my
discomfort as follows:
___________________________
0
10
No Pain
Severe Pain
Date: ___________ Signature: _________________________
ADVERTISEMENT
1 votes
Related Articles
Related forms
Related Categories
Parent category: Medical