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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: __ / __ / _____
Mon
Tue
Wed
Thur
Fri
Sat
Sun

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.