Appendix H
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)