Weekly Pain Diary

 
My
Pain Diary.
Fill in all boxes using the Numerical Scale of:

0
.....................................................
10
=
Less
=
More

Week Ending: .... / .... / ......
Mon
Tue
Wed
Thur
Fri
Sat
Sun

Morning - Overall Pain Level
             
Afternoon - Overall Pain Level              
Evening - Overall Pain Level              
Physical Symptoms.
             
How well did I sleep?              
How weak do I feel?              
How dizzy / lightheaded do I feel?              
Are my bowel movements normal?              
Is my urination output normal?              
What are my exercise levels?              
Cognitive / Emotional Symptoms
             
How is my thinking ability?              
How anxious do I feel?              
How depressed / frustrated am I?              
How angry / irratable am I?              
How happy am I?              
Possible Exacerbating Conditions
             
Is the weather affecting me?              
Is the humidity affecting me?              
Have I done too much?              
Any Comments or Notes I need to
add go here:

 

 

 

 

 

For a much clearer copy of the Pain Diary go to: http://www.painworld.zip.com.au/downloads/pain_diary.html

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Keeping A Pain Diary

You are the only one who knows how much pain you are feeling. When your doctor asks you about the pain, you probably won't remember how hard some days were. You may not remember how bad the pain was. The diary is to help you describe what is happening to you while it is happening. It will be very helpful to your doctor to know when the pain was bad, what made you feel better, and what didn't make you feel better.

Don't worry about how much to write. You don't even have to write sentences. Just write the words that describe how you are feeling. Don't worry if you miss a day. Do it when you can. If thinking about your pain every day is too hard, put the diary away for a few days and go back to it when you are ready. This is your diary. Write when you can for as many days as you can and then stop.

Keep a small notebook or tape recorder with you all day and, during the course of the day, write down what you are feeling. The following questions might help you. Write the date and time every time you write in the diary. If writing is too painful, ask a family member or friend to do it for you or record the diary on a tape recorder.

1.. Where does it hurt? List every place that hurts. Does the pain move? Does the pain feel different in different places?

2. How does the pain feel? The following words might be helpful: burning, stabbing, sharp, aching, throbbing, tingling, dull, pounding, or pressing.

3. Did you have pain when you woke up or did it start later?

4. Does the pain change during the day?

5. What, if anything, makes the pain better or worse?

6. What medicines are you taking? Do they help - never, sometimes, always? List all of the medicines your doctor gave you and all of the medicines you bought for yourself at the store.

7. Have you stopped taking any medicines because they made you constipated, sleepy or sick, or for other reasons?

8. Do you do anything to help make the pain go away other than taking medicine such as getting a massage, or meditating, etc.?

9. Do you have trouble sleeping because of the pain?

10. Does the pain keep you from spending time with family or friends?

11. Do you skip meals because of the pain??

12. How has the pain changed your life?

2002-2007 American Pain Foundation
201 N. Charles Street, Suite 710, Baltimore, Maryland 21201-4111

http://www.painfoundation.org
  

Image10-1.png picture by ejb2981    

Background & HTML Code 2004-2011 by Shorty.
Pain Chart
http://www.painworld.zip.com.au/index.html. Used with permission.

Last Update:  01/18/2011 EvieJo/Webmaster