http://www.FibroTalk.info Mark all the places that hurt and what time the pain started. S = shooting pains X = stabbing pains B = burning pains A = aching pains T = throbbing C= cramping D = dull N = numbness P = pins and needles Notes:_______________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ________________________________
PAIN DIARY WORKSHEET
Date:__________________
Front PHYSICAL SYMPTOMS
Back
Overall Morning Pain Level 1 2 3 4 5 6 7 8 9 10 Low ----------------------------------------- High How well did I sleep? 1 2 3 4 5 6 7 8 9 10 No Rest --------------------------------- Rested How dizzy do I feel? 1 2 3 4 5 6 7 8 9 10 Not dizzy --------------------------- Very dizzy How is my balance? 1 2 3 4 5 6 7 8 9 10 Steady ------------------------------------ Shaky
Overall Afternoon Pain Level 1 2 3 4 5 6 7 8 9 10 Low ----------------------------------------- High What is my fatigue level? 1 2 3 4 5 6 7 8 9 10 Not tired ---------------------------- Exhausted How is my appetite affected? 1 2 3 4 5 6 7 8 9 10 Not affected ---------------------- No appetite How is my walking ability? 1 2 3 4 5 6 7 8 9 10 Good -------------------------------------- Worst MENTAL, COGNITIVE, & EMOTIONAL
Overall Evening Pain Level 1 2 3 4 5 6 7 8 9 10 Low -------------------------------------- High How weak do I feel? 1 2 3 4 5 6 7 8 9 10 Not weak -------------------------- Very weak How are my bowels? 1 2 3 4 5 6 7 8 9 10 Constipated ---------------------------- Loose How is my urination? 1 2 3 4 5 6 7 8 9 10 Good ----------------------------------- Worst
How is my thinking ability? 1 2 3 4 5 6 7 8 9 10 Clear --------------Fuzzy--------------- Foggy How angry do I feel? 1 2 3 4 5 6 7 8 9 10 Not angry ---------------------------------- Livid How are my relations with others affected? 1 2 3 4 5 6 7 8 9 10 Not affected ---------------- Greatly affected
How anxious do I feel? 1 2 3 4 5 6 7 8 9 10 None -------------------------------- Extremely How irritable am I? 1 2 3 4 5 6 7 8 9 10 Fine -------------------------------- Extremely How is my enjoyment of life affected? 1 2 3 4 5 6 7 8 9 10 Not affected --------------- Greatly affected EXACERBATING CONDITIONS
How depressed do I feel? 1 2 3 4 5 6 7 8 9 10 None -------------------------------- No hope How happy am I? 1 2 3 4 5 6 7 8 9 10 Unhappy ------------------------------- Joyful Sensitivity to light or sound 1 2 3 4 5 6 7 8 9 10 Low -------------------------------------- High
Current Weather sunny overcast foggy rainy snowy Family/home life stress level 1 2 3 4 5 6 7 8 9 10 Low ---------------------------------------- High Medications taken:
Temperatures High________ Low________ Job stress level 1 2 3 4 5 6 7 8 9 10 Low --------------------------------------- High
Current weather is affecting me 1 2 3 4 5 6 7 8 9 10 None ---------------------------------- Greatly 1 2 3 4 5 6 7 8 9 10 Low --------------------------------------- High
Notes:
2006 Carrie Craig
Instructions for Pain Diary Worksheet
Sometimes people use this worksheet for their own personal information. But it is also a big help to your doctors. Print out a couple of copies, take them down to a copy shop for more copies, and make a three-ring binder full of a month's worth or so. You can either have copies made with one copy on each side of the page, or you can use the blank backside of the page for extra notes and information. Describe your pain the best you can. Note the intensity and duration of your pain, when it started, and what brought the pain on. Make sure you note any treatments you tried to alleviate your pain such as ice, heat, rest, music, meditation, massage, distraction, and whether or not the treatment helped to relieve your pain. It's a good idea to also list on the worksheet what medications you took and when, and whether or not or to what degree the medication helped or didn't help. Also make sure you note how the pain affects your daily activities. Keep your diary somewhere handy, where it can be easily seen and reached. It is important that the diary be filled out daily so that the information is fresh in your mind and accurate. At your next doctor's appointment, take your pain diary notebook with you. This information is extremely helpful to the doctor in many ways. It gives the doctor a better idea of the pain type and duration, things that aggravate your pain, what pain levels you are experiencing, how much medication you needed, and documents what other pain relief methods you tried. Considering that doctor's appointments are usually 15 to 30 minutes in length, be prepared to leave your pain worksheets with the doctor. Unless your doctor specifically tells you that the worksheets you give him are sufficient, it is a good idea to continue keeping up with the worksheets until he tells you to stop. You can also use this diary to help learn things about your pain. Determine what activities make your pain worse. Chart your progress while trying a new method or treatment to manage your pain. Identify what brings on flare-ups. Determine how your pain levels affect how you interact with others. Help measure your level of activity to avoid overdoing. Pain scale to help rate your pain levels:
Words you can use to help describe your pain: aching agonizing annoying biting burning cold deep exhausting gnawing horrible increasing intense miserable nagging penetrating pounding pressure pricking pulsating radiating severe sharp shooting sore spreading stabbing stinging sudden tender throbbing tingling touch sensitive traveling unbearable warm
2006 Carrie Craig, http://www.FibroTalk.info/