Neuropathic Pain Assessment Tool

Patient Name

Date

1. Does your pain have a burning quality?

Yes No

2. Is the pain like a tingling or pins and needles?

Yes No

3. Is the pain like an electric shock?

Yes No

4. Is the area sensitive to touch?

Yes No

5. Does the pain worsen with brushing or light touch?

Yes No

6. Are there periods when the pain is absent?

Yes No

7. Is the pain associated with numbness in the affected area?

Yes No

8. Any other description or comments:

Total Score (if applicable)

Clinician: