pain diagram - sports physical therapy of new york · · 2011-10-10today's date instructions...
TRANSCRIPT
TODAY'S DATE
INSTRUCTIONS
Mark these drawings according to where you are hurt or feel pain. For example, if the right side of your neck hurts, markthe drawing on the right side of the neck. Please indicate which sensations you feel by referring to the key below.
NAME
AGE
RIGHT RIGHTLEFT
LEFT HANDED
0
1
2
3
4-5
6
7-9
10
No Pain
Mild Pain; you are aware of it, but it doesn't bother youModerate pain that you can tolerated without medicationModerate pain that requires medication to tolerate
More severe pain; you begin to feel antisocialSevere pain
Intensely severe pain
Most severe pain; Emergency Room Care
PAIN LEVEL:(Check the worst & best it's been and select your current pain level)
///// STABBING | XXXX BURNING | 0000 PINS & NEEDLES | ==== NUMBNESS | ++++ ACHING
KEY
Sports PT Administrative Office | 6319 Fly Road, Suite 3, East Syracuse, NY 13057 | p 800 527 2524, 315 410 6200 | f 315 451 2095 | www.sptny.com
RIGHT HANDED
Pain Diagram
0 1 2 3 4 5 6 7 8 9 10