Pain Assessment Tool - Pain Assessment

Pain Scale Quiz

Describe How Your Pain Feels

Where Do You Feel It?

Select all relevant choices:

"Other" Area of Pain

Pain Scale Quiz

Where Does It Hurts Most?

Select all relevant choices:

"Other" Area Where It Hurts The Most

Pain Scale Quiz

How Long Has the Pain Been Around?

Pain Scale Quiz

Describe How Your Pain Feels

What Is The Best Way To Describe How You Feel?

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Pain Scale Quiz

Describe How Your Pain Feels

Is the pain constant?

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Are You Experiencing The Following Symptoms?

Pain Scale Quiz

Describe Any Previous Treatments For Your Pain

Which of the Following Treatments Have You Experienced?

Select all relevant choices:

"Other" Treatment Description

Pain Scale Quiz

Do You Have an Existing Insurance Plan?

Select all relevant choices:

Please explain your "Other" Insurance Plan:

Pain Scale Quiz

Finished!