Pain Assessment
Pain Level
style="background-color:CCCCFF">
checked/> pain level 0 (low) checked/> pain level 6 (med)
checked/> pain level 1 (low) checked/> pain level 7 (high)
checked/> pain level 2 (low) checked/> pain level 8 (high)
checked/> pain level 3 (med) checked/> pain level 9 (high)
checked/> pain level 4 (med) checked/> pain level 10 (high)
checked/> pain level 5 (med)
0 2 4 6 8 10
Pain assessment completePain assessment incomplete
Pain Characteristics
style="background-color:CCCCFF;width:88.5%">
checked/> Throbbing
checked/> Stabbing
checked/> Sharp
checked /> Aching
checked/> Burning
checked /> Numb
checked/> Shooting
checked/> Not Applicable
checked/> Other
Pain threshold
style="background-color:CCCCFF;width:88.5%">
checked/> At rest
checked /> With minimal activity
checked/> With moderate activity
checked/> With strenuous activity
checked/> Not Applicable
Rate current pain
style="background-color:CCCCFF">
checked/> pain level 0 (low) checked/> pain level 6 (med)
checked/> pain level 1 (low) checked/> pain level 7 (high)
checked/> pain level 2 (low) checked/> pain level 8 (high)
checked/> pain level 3 (med) checked/> pain level 9 (high)
checked/> pain level 4 (med) checked/> pain level 10 (high)
checked/> pain level 5 (med)
0 2 4 6 8 10

How long does each

style="background-color:CCCCFF"> checked/> 30 minutes
checked/> 1 hour
checked/> 2 hours
checked/> 3 hours
checked/> 4 hours
checked/> 6 hours
checked/> 12 hours
checked/> 24 hours