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Pain Diagram

Please mark the area of injury or discomfort on the chart below, using the appropriate symbols: Numbness Pins & Needles Burning Aching Stabbing

----------------

ooooo ooooo ooooo

^^^^^ ^^^^^ ^^^^^

xxxx xxxx xxxx

Please use the space below to describe your condition further if needed: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Date: _________________ Signature: ___________________________________________

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PN_Diagram.PDF