Pain Assessment Form
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1Pain Assessment Sheet
Name
File #
Date
Current Complaints
Progression of your current condition since it started
Same
Improved
Worse
Other
Does your present condition affect your daily activities at home or in the office? Describe:
Type of pain
Sharp
Tingling
Throbbing
Numbness
Aching
Shooting
Dull
Burning
Cramping
Stiffness
Swelling
Other _____________________________________
Other comments and notes
Describe the areas where you feel pain and provide as
much detail as possible. Mark the body outline to
indicate location of pain.
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Parent category: Medical