Pain Diagram and Rating - Dignity Health

Pain Diagram and Rating Scale

Name:

Date:

Please use the symbols below to draw the location of the pain you are having:

Numbness Pins & Needles ===== OOOOO ===== OOOOO

Burning X X X X X X X X

Stabbing / / / / / / / / / / / / / /

Aching A A A A A A A A

Please rate your current pain level on the following scale (check one):

0 1 2 3 4 5 6 7 8 9 10

(no pain)

(worst pain

possible)

Please rate your pain level when at its best on the following scale (check one):

0 1 2 3 4 5 6 7 8 9 10

(no pain)

(worst pain

possible)

Please rate your pain level when at its worst on the following scale (check one):

0 1 2 3 4 5 6 7 8 9 10

(no pain)

(worst pain

possible)

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