Body Pain And Symptoms Diagram Template
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1PAIN/SYMPTOM DIAGRAM
Patient Name: ____________________________
Date: _______________________
Please place the corresponding symbols on the diagram below as they relate to your
pain/symptoms.
Sharp Pain
Achiness
Burning
Pins and Needles
Numbness
Other
/////////
XXX
!!!!!
000000
++++
###
For the following questions use the pain scale listed below:
0
1
2
3
4
5
6
7
8
9
10
No Pain
Mild Pain
Moderate Pain
Severe Pain Unbearable
What is your pain level at rest? ________
What is your pain level at best? ______
What is your pain level with activity? _______
What is your pain level at worst? _____
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Parent category: Medical