Clinical Pain Picture

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.

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

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

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