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Pain Diary Worksheet

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					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:_______________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
________________________________                                            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/

				
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Description: Pain Diary Worksheet