Pain Assessment form
Patient Name Invalid Input
Your E-Mail Address (*) Invalid Input
Male/Female Invalid Input
Age Invalid Input
years
Height Invalid Input
Weight Invalid Input
Please List Any/All Allergies Invalid Input
When your current pain started, was there a precipitating event? Invalid Input
Others: Invalid Input
How long have you had your current pain problem? Invalid Input
Describe what the pain feels like: Invalid Input
How do the following affect your pain? (Please check one for each item.)
Lying down: Invalid Input
Standing Invalid Input
Sitting Invalid Input
Walking Invalid Input
Exercise (if applicable) Invalid Input
Medication Invalid Input
Are there other factors that make your pain…
Better? (please list) Invalid Input
Worse? (please list) Invalid Input
Please rate your pain intensity on a scale from 0 = no pain to 10 = excruciating, incapacitating worst pain possible. Write the number (from 0-10) in the spaces below:
o Your pain at its worst in the past month or since your injury Invalid Input
o Your pain at its least in the past month or since your injury Invalid Input
o Your current pain Invalid Input
How often do you have your pain? (please check one below)
Invalid Input
Please circle all of the treatments you have tried (or are currently using) for your pain.
Invalid Input
Others: Invalid Input