EVALUACION DEL DOLOR

Nombre: _____________________________________ Edad: __________________

Diagnóstico: __________________________________ Fecha: _________________

DOLOR
SI _____ NO_____

UBICACIÓN:
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INTENSIDAD:
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0 1 2 3 4 5 6 7 8 9 10

CARACTERÍSTICAS
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FRECUENCIA
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FACTORES AGRAVANTES / ATENUANTES
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