Name
Date
Circle the number that best describes the question being asked for each individual complaint.
What is your pain right now? 012345678910
What is your typical or average pain? 012345678910
What is your pain at its best? 012345678910
What percentage of your awake hours is your pain at its best?
What is your pain at its worst? 012345678910
What percentage of your awake hours is your pain at its worst?
Place an X on the areas with pain or discomfort.
