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Home | Degenerative Disc Disease, Endometriosis, Fibromyalgia & PCOS. | Template for a Pain Diary.

Template for a Pain Diary.

If you suffer debilitating chronic pain, it is suggested you keep a detailed Pain Diary.  Here is one I use.

My Pain Diary.

Don't Forget Meds!
Week Ending: __ / __ / _____

Pain Scale:        1 - No Pain  to   10 - Worst Imaginable Pain
Morning - Overall Pain Level
Afternoon - Overall Pain Level
Evening - Overall Pain Level
Physical Symptoms.
1:  Good - 10:  Not at all.
Y - Yes, N - No.
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
1:  Good  -  10:  Really Bad
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
Y - Yes, N - No.
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:






Use lots of Adjectives!  Medical professionals perfer that you be very descriptive.