Appendix G
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)