When did your pain start? __________
2: What caused the pain?_______________
3: Have you had prior pain problems? (circle one) YES NO
4: Is your pain constant? (circle one) YES NO
5: Does your pain come and go? (circle one) YES NO
6: Which terms best describe your pain?
__ aching
__ throbbing
__ pounding
__ numbing
__ pins and needles
__ burning
__ stabbing
__ other (describe in your own words)
_________________________________________
_________________________________________
HOW BAD IS YOUR PAIN?
__ mild
__ moderate
__ severe
OVERALL, IS YOUR PAIN GENERALLY:
__ improving
__ staying the same
__ worsening
IS THE PAIN WORSE:
__ upon awakening
__ in the morning
__ mid-day
__ late in the day
__ evening
__ middle of the night
__ all the time
IS YOUR PAIN RELIEVED BY:
__ ice or cold packs
__ heat (heating pad, hot shower, soak in the tub)
__ stretching
__ exercises
__ pressure
__ over-the-counter pain medications (aspirin or anti-inflammatory pills)
__ prescription pain pills
__ muscle relaxant pills
__ relaxation techniques
__ massage or manipulation
__ other
_________________________________________
_________________________________________
What are of your body is experiencing the pain?__________________________________________________
This material is intended for informational purposes only and is not a substitute for the medical advice of your doctor or any other health care professional. Always consult with your physician if you are in any way concerned about your health.
