Mai Device Pain Assessment - Post-Assessment

*(Completed by patient or provider after the device is placed)*

Please use this Scale to rate your pain:

Please rate your pain and mood at the specified time intervals after device placement

Pain Rating (1-10)

Rate your pain 2 minutes after the device is placed

Pain Rating (1-10)

Rate your pain 10 minutes after the device is placed

Pain Rating (1-10)

Rate your pain 40 minutes after the device is placed

Mood Rating (1-10)

Rate your mood 40 minutes after the device is placed

Pain Rating (1-10)

Rate your pain 2 hours after the device is placed

Mood Rating (1-10)

Rate your mood 2 hours after the device is placed

Answer the questions below once the device has been in place for >20 minutes:

Please take your time to evaluate your experience carefully.

F. Are you able to move better, or walk better? Please describe.

G. Please describe what you are feeling, both physically and mentally.

Physical Changes

Mental Changes

H. How would you describe this experience overall?

I. How does this compare to other treatments you have tried in the past?

Would you recommend this treatment to others with similar pain?

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