Healing Kneads Therapy Pain Tracking Form

Client Name: ___________________________________________________ Date: ___ / ___ / ___

 

Time: _________

Discomfort Level

__ Mild __ Moderate __ Severe

Hours since last pain-relieving medication: ____

Medication name: ___________________

Observations:

 
Fill in areas of pain on the diagram above

Time: _________

Discomfort Level

__ Mild __ Moderate __ Severe

Hours since last pain-relieving medication: ____

Medication name: ___________________

Observations:
 
Fill in areas of pain on the diagram above

Time: _________

Discomfort Level

__ Mild __ Moderate __ Severe

Hours since last pain-relieving medication: ____

Medication name: ___________________

Observations:
 
Fill in areas of pain on the diagram above
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