Acute Abdominal Pain Evaluation Form
Please complete this form to help assess symptoms related to acute abdominal pain. Do not enter sensitive personal or financial information.
Patient Initials
Age
*
Date of Symptom Onset
*
-
Month
-
Day
Year
Date
Location of Pain
*
Please Select
Right upper quadrant
Left upper quadrant
Right lower quadrant
Left lower quadrant
Epigastric
Periumbilical
Generalized
Other
Pain Intensity (1 = mild, 10 = worst)
*
Mild (1)
1
2
3
4
5
6
7
8
9
Worst (10)
10
1 is Mild (1), 10 is Worst (10)
Pain Character
*
Sharp
Dull
Cramping
Colicky
Burning
Other
Associated Symptoms
*
Nausea
Vomiting
Fever
Diarrhea
Constipation
Loss of appetite
Other
Duration of Pain (in hours)
*
Relevant Medical History
Previous abdominal surgery
Known gastrointestinal disease
Recent travel
Recent medication change
Other
Additional Notes or Observations
Submit Evaluation
Should be Empty: