PAIN
D IAGRAM
NAME
_ ______________________________________________
D ATE
_ __________________
How
l ong
h ave
y ou
h ad
p ain
?
_ ________years
_ _________months
_ __________weeks
On
t he
p ain
d iagram
b elow,
p lease
i ndicate
w here
y ou
a re
e xperiencing
p ain
o r
o ther
symptoms,
r ight
n ow.
List
t he
M AIN
r eason
y ou
a re
s eeing
t he
h ealthcare
p rovider
f or
t oday:
A
=
A CHES
B
=
B URNING
N
=
N UMBNESS
P
=
P INS
&
N EEDLES
S
=
S TABBING
O
=
O THER
P lease
m ark
a n
X
a t
t he
a rea
y ou
a re
h aving
p ain.