Name________________________________ Date_________________

Name_________________________________________________________________________Date________________________
Pleaseindicateareasofdiscomfortorconcern.IndicatePorREDforpain,TorGREENfor
Please color in the areas where you have:
tingling.NorBLUEfornumbness,SorYELLOWforstiffness.Alsoindicatedegreeofpain
Pain in RED
witha110scale(10beingIcantfunction)
NOTES
Numb/Tingling in BLUE
Tight/Stiff in GREEN
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Other in YELLOW (specify)
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Rate the areas of your pain on a scale from 0-10 (0 is no
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pain and 10 is most)
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