Pain Assessment

Pain Assessment
Today's Date

MonthDayYear
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email Address
example@example.com
Age
Height
Weight
Please list any/all allergies:
What is the main problem for which you are seeking treatment?
When your current pain started, was there a precipitating event?

Other
How long have you had your current pain problem?

How do the following affect your pain?

Rows	Decrease	No Effect	Increase
Laying Down
Standing
Sitting
Walking
Exercise
Medication

Are there other factors that make your pain better?
Are there other factors that make your pain worse?