Download the PDF HERE to print off and fill out.

NAME:_________________________

DATE:_________________________

Mark the area on your body where you feel the described sensation.
Use the appropriate symbol and include all the affected areas.

	Achy: XXX Numbness: OOO Numb-like feeling: ZZZZ Sharp / shooting: ##### Burning: ++++ Other: *****

How bad is your pain?
No pain |____|____|____|____|____|____|____|____|____| Worst Pain