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COMPLAINT AREA #1
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Complaint #1
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Side
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Complaint #1 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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How did ailment happen? When?
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Comments
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Another area? Continue with 'On' below
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Complaint area #2
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COMPLAINT AREA #2
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Complaint #2
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Side
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Complaint #2 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #3
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COMPLAINT AREA #3
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Complaint #3
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Side
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Complaint #3 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #4
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COMPLAINT AREA #4
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Complaint #4
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Side
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Complaint #4 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #5
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COMPLAINT AREA #5
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Complaint #5
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Side
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Complaint #5 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #6
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COMPLAINT AREA #6
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Complaint #6
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Side
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Complaint #6 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #7
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COMPLAINT AREA #7
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Complaint #7
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Side
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Complaint #7 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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Complaint area #8
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COMPLAINT AREA #8
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Complaint #8
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Side
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Complaint #8 better / worse?
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% of day?
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Quality of pain
• • •
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Symptoms worst when?
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Comments
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