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HPI
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Location Comments
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Quality
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Quality Comments
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Timing
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Timing Comments
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Quantity
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Quanity Comments
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Duration
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Duration Comments
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Setting
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Setting Comments
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Aggravating Factors
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Aggravating Factors Comments
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Alleviating factor
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Associated Signs
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Symptoms
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VAS
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Patient had pain other than everyday pain today
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Area where pain is felt
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Rate the pain at its worst in the past 24 hours
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Rate the pain at its least in the past 24 hours
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Number that est describes your pain on average
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Number that tells the pain right now
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% Relief provided by treatment or medication is past 24 hours
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Interference caused by pain (in past 24 hrs) with - General activity
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Interference caused by pain (in past 24 hrs) with - Mood
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Interference caused by pain (in past 24 hrs) with - Working activity
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Interference caused by pain (in past 24 hrs) with - Normal work
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Interference caused by pain (in past 24 hrs) with - Relation with other people
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Interference caused by pain (in past 24 hrs) with - Sleep
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Interference caused by pain (in past 24 hrs) with - Enjoyment life
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Treatment or Medications for pain
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