pain diagram - sports physical therapy of new york ·  · 2011-10-10today's date instructions...

TODAY'S DATE

INSTRUCTIONS

Mark these drawings according to where you are hurt or feel pain. For example, if the right side of your neck hurts, markthe drawing on the right side of the neck. Please indicate which sensations you feel by referring to the key below.

NAME

AGE

RIGHT RIGHTLEFT

LEFT HANDED

0

1

2

3

4-5

6

7-9

10

No Pain

Mild Pain; you are aware of it, but it doesn't bother youModerate pain that you can tolerated without medicationModerate pain that requires medication to tolerate

More severe pain; you begin to feel antisocialSevere pain

Intensely severe pain

Most severe pain; Emergency Room Care

PAIN LEVEL:(Check the worst & best it's been and select your current pain level)

///// STABBING | XXXX BURNING | 0000 PINS & NEEDLES | ==== NUMBNESS | ++++ ACHING

KEY

Sports PT Administrative Office | 6319 Fly Road, Suite 3, East Syracuse, NY 13057 | p 800 527 2524, 315 410 6200 | f 315 451 2095 | www.sptny.com

RIGHT HANDED

Pain Diagram

0 1 2 3 4 5 6 7 8 9 10