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:

Overall pain: None mild moderate severe extreme
0 1 2 3 4 5 6 7 8 9 10
a.   General Pain RIGHT NOW
b.   General Pain in the LAST MONTH
c.   LEAST Pain Level in LAST MONTH
d.   WORST Pain Level in LAST MONTH

WORST pain in LAST MONTH by Region: 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

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Last update: 10/13/2015