Physiotherapy Pain Assessment Form
Patient Name
Date of Birth
Assessment Date
Assessed by (Therapist)
Pain Details
Pain Location
Duration of Pain
Describe the Pain
Pain Type
Sharp
Dull
Aching
Burning
Throbbing
Other
Aggravating Factors
Relieving Factors
Pain Scale
Pain Intensity (0 = No pain, 10 = Worst pain)
Onset
Frequency
Duration of Each Episode
Associated Symptoms
Additional Notes