Appendix E
NUMERICAL PAIN ASSESSMENT SCALE
Place circle around the number that best indicates the severity of your pain.
The higher the number, the more severe your pain.
Example: This scale indicates minor pain.
| Patient Name: | |
| Patient Signature: | |
| Date: | |
| Physician: | |
| Parent/Guardian: | |
| Scale Administrator: | |
| Scale
Administrator must initial and date this completed form: |
(Initial
and date) |