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Procedure Pain Diagram
Procedure Pain Diagram
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Primary Care Provider
Today's Date
MM slash DD slash YYYY
Where Is Your Pain?
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Other area of pain (if applicable)
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Other area of pain (if applicable)
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Health History
Changes in your health
Any changes in your health since your last visit?
Tests or Surgeries
Any diagnostic tests
Any diagnostic tests or surgeries since last visit?
Average Pain Intensity
Select the number to indicate your average pain intensity over the past week:
Select a number
0 (None)
1 (Mild)
2 (Mild)
3 (Mild)
4 (Moderate)
5 (Moderate)
6 (Moderate)
7 (Severe)
8 (Severe)
9 (Severe)
10 (Most)
Relief
Select the percentage of how much relief a procedure has provided (if applicable)
Select a number
0% (None)
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% (Complete Relief)
Relief
How long did you get relief from the previous procedure? (# of days, months, years)
Do you have any allergies to the following?
Contrast Dye
Yes
No
Iodine
Yes
No
Latex
Yes
No
Are you on blood thinners?
Yes
No
If yes, what medication?
Last Dose:
INR (if applicable) date:
MM slash DD slash YYYY
Are you taking any antibiotics?
Yes
No
Do you have any bleeding disorders?
Yes
No
Are you pregnant?
Yes
No
Do you have a pacemaker?
Yes
No
Do you have a spinal cord stimulator?
Yes
No
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