Patient Pain Chart Template printable pdf download

Patient Pain Chart Template

PATIENT PAIN CHART

PATIENT NAME: ________________________________

DATE: ____________

Weight: ___________ lbs

Height: __________ ft. __________ in

Please describe your condition:

___________________________________________________________________________

Mark the areas on the body where you feel the described sensations.

Numbness Pins & Needles

Burning Aching

Stabbing





------

OOOOO

XXX

FRONT

BACK

(right)

(left)

(right)

The line below represents the intensity of your pain. Please mark an “X” at the position on the

scale which indicates how much pain you feel at this time.

__________________________________________________________________________

No pain

Worst Pain Imaginable

Signature: __________________________________________________________________

Patient Pain Chart Template