Stomach Pain Assessment Form
Use this form to describe your stomach pain, related symptoms, likely triggers, and any helpful context.
Symptom Overview
Pain Location
*
Upper abdomen
Lower abdomen
Center of abdomen
Left side
Right side
General/whole stomach
Other
Pain Intensity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Pain Type / Quality
*
Cramping
Burning
Sharp
Dull
Bloating
Aching
Other
When the Pain Started
*
Today
Within the last 24 hours
2-3 days ago
4-7 days ago
More than a week ago
Describe the pain in your own words
Associated Symptoms and Triggers
Associated symptoms
Nausea
Vomiting
Diarrhea
Constipation
Bloating
Fever
Loss of appetite
Heartburn
Gas
Dizziness
None
When does the pain get worse?
After eating
Before eating
With movement
At rest
Other
How much does the pain affect your daily activities?
No effect
1
2
3
4
5
6
7
8
9
Severe effect
10
1 is No effect, 10 is Severe effect
Patterns, Self-Care, and Follow-Up
Remedies or actions tried and whether they helped
Has this happened before?
*
Yes
No
Unsure
Preferred follow-up method
Please Select
Email
Phone
No follow-up needed
Submit Form
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