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Don't Forget Meds! |
| Week Ending: __ / __ / _____ |
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Pain Scale: 1 - No Pain to
10 - Worst Imaginable Pain |
Morning - Overall Pain Level
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| Afternoon - Overall Pain Level |
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| Evening - Overall Pain Level |
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Physical Symptoms.
1: Good - 10: Not at all.
Y - Yes, N - No. |
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| How well did I sleep? |
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| How weak do I feel? |
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| How dizzy / lightheaded do I feel? |
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| Are my bowel movements normal? |
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| Is my urination output normal? |
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What are my exercise levels? |
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Cognitive / Emotional Symptoms
1: Good - 10: Really Bad |
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| How is my thinking ability? |
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| How anxious do I feel? |
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| How depressed / frustrated am I? |
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| How angry / irratable am I? |
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| How happy am I? |
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Possible Exacerbating Conditions
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| Is the weather affecting me? |
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| Is the humidity affecting me? |
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| Have I done too much? |
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Any Comments or Notes I need to
add go here: |
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