Name:
Birthdate: 		Click on the description(s) which best represents your pain and
hold your mouse button to draw on the affected area of the body.
⇙ Be sure to press "Send to Dr Office" when you're done drawing!
If you cannot see the drawing or cannot draw, you can complete the pain diagram at your first visit.

Unfortunately, your browser does not support our pain diagram application.
We are sorry for the inconvenience.
Please use one of the supported browsers listed below, or click here to print out the pain diagram which you fill out and send to us via mail or fax.

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Burning
Aching
Numbness
Pins & needles
Stabbing
Shooting pain
Referred pain
Referred pain starts in one area
and causes pain elsewhere.
Clear All
Eraser