• Author / Uploaded
• Laura Paola Corredor Nieto

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Physical Medicine and Rehabilitation Occupational/Musculoskeletal Medicine EMG and Nerve Conduction Studies Fluoroscopic-Guided Injection Procedures Independent Medical Exams (IMEs) Pain Management Sports Medicine

New Jersey Medical School University Rehabilitation Associates 90 Bergen Street, D.O.C. Suite 3100 Newark, N.J. 07103-2499 Tel: 973-972-2802 Fax: 973-972-2825

Name [Nombre]:_____________________ _______

Date [Fecha]:_________________________

Pain Drawing [dolor de dibujo] Only for the pain in the body region that you are being seen for today: [Sólo para el dolor en la región del cuerpo que se le está visto para hoy:] Choose the symbol(s) shown below that best describe(s) the pain you are having (e.g. ∆ ∆ ∆ means it is an aching [i.e. dull] type of pain). [Seleccione los símbolo(s) que se muestra a continuación que mejor describen el dolor que está teniendo (Ejemplo: ∆ ∆ ∆ significa que es una las)] Aching Numbness Pins & Needles Burning Stabbing or Sharp Other [Doloroso] [Dormido] [Pinchasos] [Ardor] [Punaldas] [Otro] ∆∆∆ === 000 XXX /// ... Draw onto the diagram below, using the symbol(s) you have chosen above, to show where your pain is located. [Dibujar en el diagrama de abajo, usando el símbolo(s) que ha elegido anteriorment, para mostrar su dolor cuando se encuentra.] FRONT [FRENTE] RIGHT [DERECHA]

LEFT [IZQIERDA]

LEFT [IZQAIERDA]

BACK [ESPALDA] LEFT [IZQIERDA]

RIGHT [DERECHA]

RIGHT [DERECHA]