Digital Pain Matrix - 2021
(to be completed by a trained clinician)

       ID:         DATE:           TIME (24hr): 


INSTRUCTIONS: On a scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable,
please rate your pain (may use half numbers):
Overall pain: None mild moderate severe extreme
0 1 2 3 4 5 6 7 8 9 10
Pain RIGHT NOW
Worst in last 24 hours
Worst in last month


INSTRUCTIONS: Please rate your pain by checking the one number that best describes your pain
at its worst in the past month, for each region in which you have had pain:
Regions affected by pain: None mild moderate severe extreme
0 1 2 3 4 5 6 7 8 9 10
1.   LEFT   - Shoulder
2.   LEFT   - Upper arm/elbow
3.   LEFT   - Lower arm/wrist/hand
4.   RIGHT - Shoulder
5.   RIGHT - Upper arm/elbow
6.   RIGHT - Lower arm/wrist/hand
7.   LEFT   - Hip
8.   LEFT   - Upper leg/knee
9.   LEFT   - Lower leg/ankle/foot
10. RIGHT - Hip
11. RIGHT - Upper leg/knee
12. RIGHT - Lower leg/ankle/foot
13. Neck/cervical spine
14. Upper back/thoracic spine
15. Lower back/lumbo-sacral spine
16. Head /headache
17. LEFT   - Jaw
18. RIGHT - Jaw
19. Chest
20. Stomach ache / Abdominal pain


TEXT FOR YOUR RECORDS

APW  maximum score = 80

0    -  19      normal
20  -  39      mild
40  -  59      moderate
60  -  69      severe
70  -  80      extreme

DATA FILE

Digital Pain Matrix designed by: J. Wesson Ashford, Mark Perlow, Quai Wentt
Electronic mail address: washford@medafile.com
Forms and papers provided on this site may be copyright protected by their authors or publishers.
HTML code copyright by J. Wesson Ashford, M.D., Ph.D., to retain rights for use.
Dr. Ashford is licensed to practice medicine in the states of California and Kentucky.
Last update: 03/04/2021