Appendix D
VISUAL ANALOG PAIN ASSESSMENT SCALE (VAS)
Place a mark along the line that best indicates your pain. The closer you make the mark to the top of the line, the more severe your pain.
| Patient Name: |
|
| Patient Signature: |
| Date: |
| Physician: |
|
| Parent/Guardian: |
| VAS Administrator: |
| VAS Administrator must initial and date this completed form: |
(Initial
and date) |