Quadruple Visual Analogue Scale Form

Download the PDF version or fill out and submit the form below.

  • QUADRUPLE VISUAL ANALOGUE SCALE
  • Please 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 Pain
  • Please enter a value between 0 and 10.
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  • Please enter a value between 0 and 10.