Wake Forest | 919.556.4678

Cary | 919.468.0955

Patient First Name*
Patient Last Name*
Date Of Birth*
MM slash DD slash YYYY
Please rate your pain on the following three scales by assigning a number to your pain intensity. Use the upper line to describe your pain level right now. Use the other two lines to rate your pain at worst and at best over the past 24 hours.
Rate Your Pain ( RIGHT NOW )*
0 1 2 3 4 5 6 7 8 9 10
0=No Pain | 10=Extremely Intense
Rate Your Pain ( AT WORST )*
0 1 2 3 4 5 6 7 8 9 10
0=No Pain | 10=Extremely Intense
Rate Your Pain ( AT BEST )*
0 1 2 3 4 5 6 7 8 9 10
0=No Pain | 10=Extremely Intense
Please describe the location of your symptoms.*
Today's Date: 03/29/2023
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