Pain Assessment Form
Pain Assessment Form
Name
Height(cm)
Weight(kg)
BMI(Body Mass Index)
Age
Date of Birth
 /
Day
 /
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
Female
Male
Other
E-mail
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address of Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where did you hear about this form?
Please Select
Brochures
TV
Advertises
Friend, Family
Hospitals, Health Centers
Other
Back
Next
Please enter the origin date of your pain
 /
Day
 /
Month
Year
2 digit day, 2 digit month, 4 digit year
Origin Date of Your Pain
Please describe your pain and location(s) of your pain
eg. Stabbing in my left shoulder
From 1 to 10, How bad is your pain
Not much
1
2
3
4
5
6
7
8
9
Very bad
10
1 is Not much, 10 is Very bad
Can you describe the feeling of your pain?
Burning
Stabbing
Penetrating
Numb
Nagging
Gnawing
Aching
Throbbing
Tender
Shooting
Sharp
Intermittent
Unbearable
Constant
Other
Type a question
Rarely
Sometimes
Often
Continuous
In which period of the day you feel the pain mostly?
Morning
Afternoon
Evening
Night
Other
How is your pain getting by the time?
Getting Better
Getting Worse
Is there something that you do to get better when you feel pain?
eg. massaging my forehead
Is there any movements, actions or activities that triggers your pain?
eg. Raising my hand
Are you taking any medicine or medical assistance for your pain? If you do, please type the name and type how often do you take
eg. Nurofen = 1 per day
Please select the option; how the pain affects your
Rows
1
A little
2
3
4
5
6
7
8
9
10
So much
Sleep
1
2
3
4
5
6
7
8
9
10
Daily routine
11
12
13
14
15
16
17
18
19
20
Your work
21
22
23
24
25
26
27
28
29
30
General mood
31
32
33
34
35
36
37
38
39
40
Relationships
41
42
43
44
45
46
47
48
49
50
Life quality
51
52
53
54
55
56
57
58
59
60
Please upload if you have any previous medical examination reports, analysis related to your pain
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