Initial Pain Evaluation Form - Phoenix Thera-Lase Systems 2026

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The document is an Initial Pain Evaluation Form from Phoenix Thera-Lase Systems, LLC, designed to assess a patient's pain levels and activity capabilities. It includes questions about the patient's ability to walk unassisted, average activity level, history of pain, and specific pain areas on a diagram. The form also features a pain rating scale for patients to indicate their current pain intensity.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date and your personal information, including last name, first name, and middle initial. This ensures that your evaluation is properly documented.
Answer the first question regarding your ability to walk unassisted by selecting 'YES' or 'NO'.
Indicate your average activity level by choosing from Light, Moderate, or Vigorous. Refer to the provided examples for clarity.
Respond to whether you have experienced pain beyond everyday types today by selecting 'YES' or 'NO'.
Use the diagram provided to shade areas of pain and number them accordingly. Mark the area that hurts the most with an 'X'.
Rate your current pain level by circling a number on the scale from 0 (No Pain) to 10 (Bad Pain) for each identified pain area.

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