The Pain Snapshot

A clearer way to tell your care team how pain is affecting your life. Fill this out before your appointment and hand it to your provider. Check what fits and fill in the blanks.

Download & print the Pain Snapshot (PDF)

What's on the sheet

Five quick steps, then one sentence you can read aloud to your provider.

1 — How much is pain limiting you today?

Check the one line that fits best right now.

0No pain.

1–2Mild It's there, but I can ignore it. It doesn't stop me from anything.

3–4Nagging I notice it constantly. I can still do most things, just slower or with breaks.

5–6Disruptive It interrupts me. I have to change, pause, or drop activities. Hard to concentrate.

7–8Severe It runs my day. I can't do most normal activities or focus on much besides the pain.

9Crushing I can't function. I can barely move or talk. All I can do is get through it.

10Emergency Unbearable. I need help now.

2 — My baseline vs. today

On a normal day, my pain is about ____ / 10. Right now, today: ____ / 10.

3 — Today, pain is stopping me from...

Sleeping · Standing or walking · Bathing or dressing · Work or chores · Concentrating · Mood / patience · Being present with family

4 — My pain feels like...

Circle every word that fits. Burning · Stabbing · Throbbing · Electric / shooting · Crushing · Aching · Cramping · Tearing · Pins & needles · Other: ____

5 — Since my last visit

My pain is: Better · About the same · Worse. Worst moment: ____ / 10. Best moment: ____ / 10.

Say it in one sentence
Fill in the blanks, then read it aloud to your provider. “On a normal day my pain is a ______, but today it is a ______. It is stopping me from ____________________. It feels ____________________, and since my last visit it has gotten ____________.”

This is a communication tool to help you describe your pain. It is built from established pain-assessment methods but is not itself a clinically validated instrument, and it does not replace your provider's evaluation, diagnosis, or advice.

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