Pain Location, Intensity & Frequency Questionnaire Form
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1P
L
, I
& F
Q
AIN
OCATION
NTENSITY
REQUENCY
UESTIONNAIRE
______________________________
D
________________
PATIENT NAME
ATE
K
EY
U
SE LETTERS BELOW TO INDICATE TYPE AND LOCATION OF DISCOMFORT
A = A
B = B
C = S
CHE
URNING
TABBING
N = N
P = P
& N
O = O
UMBING
INS
EEDLES
THER
W
C
:____________________________________________
HAT IS YOUR CURRENT PRIMARY
OMPLAINT
S
C
:___________________________________________________________
ECONDARY
OMPLAINT
C
:____________________________________________________________________
OMMENTS
P
.
LEASE USE THE ABOVE CODES TO EXPLAIN AND LOCATE THE AREAS THAT ARE BOTHERING YOU
P
& F
0 – 10 P
LEASE RATE THE INTENSITY
REQUENCY OF YOUR PAIN USING
AIN SCALE
(0=N
, 10=M
)
O PAIN
OST SEVERE IMAGINABLE
P
_____; A
_____,
_____%
;
RESENT PAIN LEVEL
VERAGE PAIN LEVEL
PRESENT
OF THE TIME
W
_____,
_____%
;
_____,
____%
.
ORST PAIN LEVEL
PRESENT
OF THE TIME
LOWEST PAIN LEVEL
PRESENT
OF TIME
W
?_______________________________________________________
HAT WILL INCREASE YOUR PAIN
W
/
?_______________________________________
HAT GIVES YOU THE GREATEST RELIEF
CONTOL OF PAIN
W
?__________________________________________
HAT ARE YOU UNABLE TO DO BECAUSE OF YOUR PAIN
______________________________________________________________________
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Parent category: Life