Body Pain Location Chart With Symptoms Questionnaire
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1
2Symptoms
Major Complaint:___________________________________________________________________________________
Start of symptoms?_______________________________________ Are symptoms/condition getting worse? Yes
No
What aggravates it?___________________________________What relieves it?_________________________________
Rate the severity of pain (0-none to 10-severe) : AREA 1:___________ 0 1 2 3 4 5
6 7 8
9
10
AREA 2:___________ 0 1 2 3 4 5
6 7 8
9
10
OTHER:___________ 0 1 2 3 4 5
6 7 8
9
10
Is the pain constant or does come and go?________________________________________________________________
What activities are difficult? Sitting
Standing
Lying Down Bending Walking
Other____________________
Description of the pain: Sharp
Dull
Aching
Burning
Shooting
Throbbing
Numbness
Tingling
Stiffness
Cramping
Swelling
Other____________________________________________________________
Have you ever had the same or similar condition/symptoms before? Yes
No
If yes, when?_____________________
Have you already received other treatment for your current condition?__________________________________________
Please list any other healthcare providers that you are currently under their care:
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Provider Name_________________________________________________Date of last visit_____/_____/_______
Body Chart
What desired activities are you unable to do
Shade your symptom area. Place an “S” for sharp pain, a “T”
because of your condition or pain?
for tingling, a “N” for numbness and a “D” for dull pain:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Daily Habits
Do you exercise regularly? Yes No
Describe?_________________________________________________________
Do you smoke or use tobacco products? Yes No How much per day?_________________________
How much alcohol do you consume on a weekly basis?______________________________________
How much coffee, tea, or other caffeinated beverages do you consume per day?___________________
Patient Name:_____________________________________Date:_____/_____/_______Patient I.D.______________
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