Template: Medical IntakePain Assessment Form Form TemplateUse This Template 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 Pain12345 - Moderate Pain678910 - Worst PainPain Duration *Less than 1 week1-2 weeks2-4 weeks1-3 monthsMore than 3 monthsDescribe the nature of your pain (e.g., sharp, dull, throbbing). What relieves your pain? What worsens your pain? Signature *Sign HereUse This Template