5 out of 10
Confidential Patient Information Part II
* = Required Information
910 N Hwy 146, Suite. A
Baytown, TX 77520
Phone: 281-837-7571
Fax: 281-664-3789
281-837-7573
Excellent Good Fair Poor
Please rate your pain on a scale of 0-10,
0 being no pain and 10 being the worst pain you can ever imagine
0
0
No Hurt
0
1-2
Hurts Little Bit
0
3-4
Hurts Little More
0
5-6
Hurts Even More
0
7-8
Hurts Whole Lot
0
9-10
Hurts Worst
lines
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1 2 3 4 5 6 7 8 9 10
Sharp Dull Aching Burning Stabbing Shooting