Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pain Assessment Form
Pain Assessment Form Please describe your current pain and symptoms.
Location of Pain *
Pain Intensity (0-10) *
- 0 - No Pain
- 1
- 2
- 3
- 4
- 5 - Moderate Pain
- 6
- 7
- 8
- 9
- 10 - Worst Pain
Pain Duration *
- Less than 1 week
- 1-2 weeks
- 2-4 weeks
- 1-3 months
- More than 3 months
Describe the nature of your pain (e.g., sharp, dull, throbbing).
What relieves your pain?
What worsens your pain?
Signature
Date
Pain Assessment Form template from formisoft.com. formisoft.com/intake-templates/pain-assessment