Eric Young

 
 Quantum Pain and Orthopedics 
 Tel:  
 Fax:  
 QUANTUM 
 Email: Info@QuantumPainOrtho.com 
 PAIN AND ORTHOPEDICS 
 www.QuantumPainOrtho.com 
 SymptomDescription. 
 1. 
 Where is your pain? 
 5 
 Is your pain: 
 Sharp 
 Dull 
 Burning 
 Pulling 
 Shooting 
 Aching 
 Throbbing 
 Stabbing 
 Do you have associated symptoms of: 
 Numbness 
 Tingling 
 Cramping 
 Decreased sensation 
 Weakness or clumsiness 
 Other Type of Pain (Describe): 
 
 13. Using the pain scale (0-10), best describe the level of your pain at its worst: 
 5 
 14. Using the pain scale (0-10), best describe the level of your pain at its least: 
 FRONT 
 BACK 
 Use the diagram to show where you have your pain. Mark the area with 
 an (X) that best describes your pain location: 
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 R 
 L 
 R 
 Megan Morris
 Megan Morris
 03 November 2019
 Patient/Guardian'Signature 
 Print Name 
 Date 
 from 
 QPO20180553
