Quadruple Visual Analog Scale
Please select the number (by sliding the button), that best describes the question being asked. Choose between zero (0) and ten (10). Zero, is no symptoms at all, and ten (10) is the worst possible pain imaginable.
Patient Name (required)
1. What is your pain level right now?
2. What is your typical or average pain level? (Over the last 3 months or since you last answered this form.)
3. What is your pain at its best? (How close to "0" does it get.)
4. What is your pain level at its worst? (How close to "10" does it get.)
5.What percentage of your waking hours is the pain at its worst?
6. In this section you can type additional information to include with your submission, or simply leave it blank.
Should be Empty: