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Body Pain Form

Where is your pain now? Please mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Mark the areas of radiation using the symbols indicated below. Include all affected areas. Just to complete the picture, please draw in your face.


Please click and use these above markings to show what happened to your head on the day of injury.

If you are not able to fill the diagram form online, please download the diagram, print it and add the markings over it.

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