Self Pain Assessment 1 2 3 4 Pain Assessment 1) Where do you have pain? Neck Upper back Low back Shoulder Hip Knee Ankle 2) Typical pain intensity? No pain Mild Moderate Severe Worst imaginable pain Next Medical History 3) When did pain start? Less than 1 week Less than 1 month 1–6 months More than 6 months 4) Did pain start due to injury? Yes due to accident Yes due to heavy lifting Not from injury Not sure 5) Disease history? Arthritis Slipped disc Osteoporosis Spondylitis Diabetes Scoliosis None of the above Next Back Lifestyle Information 7) Occupational position? Prolong sitting on floor Prolong sitting on chair Prolong standing Long hour travelling Lifting heavy weights Inactive physically long time None of the above Next Back Submit Submit Back
