Appendix E
BODY DIAGRAM ASSESSMENT SCALE
Use this diagram to show where you have your pain. Mark the area with the symbol that best describes your pain:
| Aching Pain | ******* |
| Burning Pain | xxxxxxxx |
| Numbness | ====== |
| Pins and needles | OOOOO |
| Stabbing pain | / / / / / / |
| Patient Name: |
|
| Patient Signature: |
| Date: |
| Physician: |
|
| Parent/Guardian: |
| Assessment Administrator: |
| Assessment Administrator must initial and date this completed form: |
(Initial
and date)
|