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Get the free Please circle the numbers to indicate your typical pain level.

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Please mark an X on the body part’s) where you have pain, an 0 on the body part’s) where you have numbness. Right PATIENT NAME: DATE: Left Right PLEASE CIRCLE THE NUMBERS TO INDICATE YOUR TYPICAL
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Read the instructions carefully: Before filling out the form, it is important to carefully read the instructions provided. This will give you a clear understanding of how to correctly fill out the form.
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Provide accurate information: Please circle form numbers typically require you to indicate your selection by circling the corresponding number. Make sure to accurately select the appropriate number to indicate your response.
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Use a pen or pencil: It is recommended to use a pen or pencil that is easily visible. This will ensure that the circled numbers are legible and easy to read.
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