Dr. Myatt’s Pain Drawing
Please draw in the appropriate location of pain with the symbol that best describes the discomfort that you are presently experiencing. Be as accurate and complete as you can. Then answer the questions below. Patient Name:
Date:
Sharp and Stabbing = ++++++
Dull and Achy = VVVVV
Pins and Needles = OOOOO
Numbness = ////////////
Spasm or Cramp = SSSSS
Stiff or Tight or Tense = XXXXX 
What makes the pain better?
What makes it worse?
Have you ever had this pain before?
If yes, when?
When did the pain begin?
Why did the pain begin? (If you know)
How often do you have the pain?
A – Occasionally
B – Half the time
C – Frequently
D – Constantly
How intense is the pain?
1 – slight
2 – Mild
3 – Moderate
4 – Severe
Dr. Myatt’s Wellness Club P.O. Box 900, Snowflake, AZ 85937
1-800-DR.MYATT – FAX: (928) 536 5691
Dr. Myatt’s Wellness Club
