Appendix F

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:

Patient Name: ___________________________________________________________________________
Patient Signature: _______________________________________________________________________
Date: __________________________________________________________________________________
Physician:_______________________________________________________________________________
Parent/Guardian: ________________________________________________________________________
Assessment Administrator:_________________________________________________________________
Assessment Administrator must initial and date this completed form: _______________________________
(Initial and date)

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