Chest Pain Assessment

Where do you feel the pain in your chest?

Left side

Right side

Center

Please select an option before proceeding.

Is the pain localized or spreading to other areas?

Localized to the chest.

Spreading to the arms or shoulders.

Spreading to the neck or jaw.

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How would you describe the pain?

Sharp

Dull

Pressure-like

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When do you experience the pain?

During physical activity

At rest

After eating

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Do you experience shortness of breath or dizziness with the pain?

Yes, both shortness of breath and dizziness

Yes, only shortness of breath

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How long have you been experiencing this pain or issue?

Less than a week

1-4 weeks

Over a month

Other

How did the pain start?

Sudden

Gradual

Do you know the cause of pain?

Yes

How would you rate your pain on a scale of 1-10?

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Have you taken any medications or treatments for this pain?

Yes

Is this pain the first time you’ve experienced it, or have you had similar pain before?

Yes, this is the first time I’m experiencing this type of pain.

No, I’ve had this type of pain before, but it went away after a while.

No, I’ve had similar pain before, and it has been recurring.

Have you ever been involved in a road traffic accident (car, bike, or pedestrian)?

Yes, I’ve been in a road traffic accident before and sustained injuries.

Yes, but I did not experience significant injuries at the time.

No, I’ve never been in a road traffic accident.

Have you ever had any fractures or discitys in your body, particularly around the affected area?

Yes, I have had a fracture or discity in the area experiencing pain.

Yes, I’ve had a fracture or discity in another area of my body.

No, I’ve never had any fractures or discitys.

Have you undergone any surgeries in the past, especially related to the area experiencing pain?

Yes, I’ve had surgery in the affected area (e.g., hip, shoulder, back).

Yes, I’ve had surgeries elsewhere in my body but not in the affected area.

No, I have never had any surgeries.

Do you have any other medical conditions that might be related to the pain, such as arthritis, diabetes, or autoimmune disorders?

Yes, I have a medical condition (e.g., arthritis, diabetes, fibromyalgia) that may be related to the pain.

No, I don’t have any known medical conditions related to the pain.

I’m not sure, but I’ve been diagnosed with other health issues.

Personal Details

First Name

Last Name

Body Type

Age

Minor Name

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Chest Pain Assessment

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