Pain Assessment Form

Evaluates a patient's pain characteristics, location, severity, and impact on daily activities.

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Evaluates a patient's pain characteristics, location, severity, and impact on daily activities.

Patient Full Name*

Date of Birth*

Location of pain (e.g., lower back, left knee)*

Current pain level (1 = minimal, 5 = severe)*

Type of pain experienced

AchingSharp / stabbingBurningThrobbingNumbness / tinglingRadiating

How often do you experience this pain?*

Factors that worsen pain

Physical activityRest / inactivityCold weatherStress

How does pain affect your daily activities and quality of life?

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healthcarepainassessmentchronic painpatient