Chiropractic Pain Diagram Template
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1Healing Hands Chiropractic
Dr. Beth Tedesco, D.C.
Name:________________________________________
Date:_________________________________
PAIN DIAGRAM
On the diagrams below, please use these symbols to identify your symptoms:
1.
Aching
∩∩∩∩
Burning
x x x x
Numbness
■ ■ ■ ■
Stabbing
| | | | |
Pins & Needles
○ ○ ○ ○
Stiffness
+ + + +
2. Please rate the level of your pain:
1
2
3
4
5
6
7
8
9
10
●-----------------------------------------------------------------------------------------------------------------●
No Pain
Worst Pain
Imaginable
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0 votes
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