Date of Assessment

Name

Date of Birth

Contact Number

Where is your pain located?

Check all that apply

• Neck

• Back

• Shoulders

• Legs

• Arms

What type of pain are you experiencing?

Check all that apply.

• Sharp

• Throbbing

• Aching

• Burning

• Numbness

Pain Scale

1 = Mild, 10 = Severe

Is your pain constant or intermittent?

• Constant

• Intermittent

How long have you been experiencing this pain?

Have you tried any treatments for this pain?

If yes, please list:

Additional Information

Is there anything else you’d like to share about your pain?