Quadruple Visual Analogue Scale Form Download the PDF version or fill out and submit the form below. QUADRUPLE VISUAL ANALOGUE SCALEPatient Name* First Last Email* PhonePlease read carefully: Instructions: Please enter the number that best describes the question being asked. Note: If you have more than one complaint; please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. 0 = No Pain 10 = Worst Possible PainWhat is your neck pain RIGHT NOW?Please enter a number from 0 to 10.What is your back pain RIGHT NOW?Please enter a number from 0 to 10.What is your headache pain RIGHT NOW?Please enter a number from 0 to 10.What is your TYPICAL or AVERAGE neck pain?Please enter a number from 0 to 10.What is your TYPICAL or AVERAGE back pain?Please enter a number from 0 to 10.What is your TYPICAL or AVERAGE headache pain?Please enter a number from 0 to 10.What is your neck pain level AT ITS BEST (How close to "0" does your pain get at its best)?Please enter a number from 0 to 10.What is your back pain level AT ITS BEST (How close to "0" does your pain get at its best)?Please enter a number from 0 to 10.What is your headache pain level AT ITS BEST (How close to "0" does your pain get at its best)?Please enter a number from 0 to 10.What is your neck pain level AT ITS WORST (How close to "10" does your pain get at its worst)?Please enter a number from 0 to 10.What is your back pain level AT ITS WORST (How close to "10" does your pain get at its worst)?Please enter a number from 0 to 10.What is your headache pain level AT ITS WORST (How close to "10" does your pain get at its worst)?Please enter a number from 0 to 10. Δ
