Pain Drawing
Mansfield Spinal Care · Keith N. Jensen, DC · 1600 N Hwy 287 Suite 103, Mansfield, TX · (817) 477-2907
Name: Date of Birth: Today's Date:
Mark the drawings with the letters below — put each letter exactly where you feel that kind of pain. Use as many letters and spots as you need, on the drawing that matches where the pain is (pain on the back of your leg goes on the Back drawing). The L and R are your left and right. Bring this sheet to your appointment.
BACK VIEW
(seen from behind)
L
R RIGHT SIDE
(your right side)
LEFT SIDE
(your left side)
FRONT VIEW
(facing you)
R
L A = Ache B = Burning N = Numbness P = Pins & Needles S = Stabbing O = Other
If you used O (Other), describe the pain in your own words:
At its LEAST, my pain is/ 10 At its WORST, my pain is/ 10