Ashford-Perlow-Wentt/Analog Pain Worksheet (APW)
(to be completed by a trained clinician)

       ID:         DATE:           TIME (24hr): 


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

Overall pain: None mild moderate severe extreme
0 1 2 3 4 5 6 7 8 9 10
General 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

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Last update: 10/13/2015