Pain Assessment Tool
This is a general pain assessment tool, no matter your score, it doesn’t mean you don’t hurt. Here are a few tips and tricks you can implement to help alleviate pain.

• A healthy diet
• No smoking
• Regular daily exercise
• Conservative Physical Therapy
• Deep breathing or mediation

We are here to help and encourage you to make an appointment with us to talk about your pain. Thank you.

Email address *
Name
Your answer
What is the location of your Pain? *
Your answer
When did your Pain first start? *
MM
/
DD
/
YYYY
Is your Pain caused by accident or trauma?
What is your Pain level most of the time?
What is the frequency of your Pain?
Your answer
What best describes your Pain?
What makes your Pain worse?
What does your Pain interfere with?
What makes your Pain better? *
A copy of your responses will be emailed to the address you provided.
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