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Template: Medical Intake
Pain Assessment Form
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Assess pain levels and symptoms for patients.
This is a preview of the template. Click here to use it.
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
*
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