Clinical Screening

Pain Assessment

Help your physician understand your pain. Your responses are submitted securely to your chart.

Patient Information

First Name *

Last Name *

Date of Birth *

When did your pain start?

What caused your pain?

Since the pain began, has it changed?

Please select all words that might describe your pain

How often does your pain occur?

How long does your pain last?

Select number to indicate your highest pain over the past week (1-5)

Select number to indicate your lowest pain over the past week (1-5)

Select to indicate how much your pain interfered with your activities this week (1-5)

Bending

Sitting

Standing

Walking

Coughing/Sneezing

Lying Down

Lifting

Climbing

Signature (typed name) *

Date *