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.

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