http://www.FibroTalk.info Date:__________________
PAIN DIARY WORKSHEET
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:_______________________________
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________________________________ Front Back
PHYSICAL SYMPTOMS
Overall Morning Pain Level Overall Afternoon Pain Level Overall Evening Pain Level
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Low ----------------------------------------- High Low ----------------------------------------- High Low -------------------------------------- High
How well did I sleep? What is my fatigue level? How weak do I feel?
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
No Rest --------------------------------- Rested Not tired ---------------------------- Exhausted Not weak -------------------------- Very weak
How dizzy do I feel? How is my appetite affected? How are my bowels?
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Not dizzy --------------------------- Very dizzy Not affected ---------------------- No appetite Constipated ---------------------------- Loose
How is my balance? How is my walking ability? How is my urination?
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Steady ------------------------------------ Shaky Good -------------------------------------- Worst Good ----------------------------------- Worst
MENTAL, COGNITIVE, & EMOTIONAL
How is my thinking ability? How anxious do I feel? How depressed do I feel?
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Clear --------------Fuzzy--------------- Foggy None -------------------------------- Extremely None -------------------------------- No hope
How angry do I feel? How irritable am I? How happy am I?
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Not angry ---------------------------------- Livid Fine -------------------------------- Extremely Unhappy ------------------------------- Joyful
How are my relations with others affected? How is my enjoyment of life affected? Sensitivity to light or sound
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Not affected ---------------- Greatly affected Not affected --------------- Greatly affected Low -------------------------------------- High
EXACERBATING CONDITIONS
Current Weather Temperatures Current weather is affecting me
sunny overcast foggy 1 2 3 4 5 6 7 8 9 10
rainy snowy High________ Low________ None ---------------------------------- Greatly
Family/home life stress level Job stress level
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Low ---------------------------------------- High Low --------------------------------------- High Low --------------------------------------- High
Medications taken:
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 exhausting penetrating sharp tender
agonizing gnawing pounding shooting throbbing
annoying horrible pressure sore tingling
biting increasing pricking spreading touch sensitive
burning intense pulsating stabbing traveling
cold miserable radiating stinging unbearable
deep nagging severe sudden warm
2006 Carrie Craig, http://www.FibroTalk.info/