MY WEEKLY PAIN DIARY by haj90599

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									PAIN                                        MY WEEKLY PAIN DIARY                             Use this pain diary to record you pain, daily activities, and your medications.
                                                                                             If you are experiencing severe pain, call your healthcare provider immediately.

AWARENESS
MONTH                                       NAME
September 1-30                              WEEK                 MONTH                YEAR

                           TIME OF PAIN             ACTIVITIES       WHERE IS PAIN?            LEVEL OF PAIN           1ST MEDICATION              2ND MEDICATION            LIST ADDITIONAL
                                                   CAUSING PAIN
PLEASE RECORD EACH DAY




                                                                                                                                                                              MEDICATIONS,
                         • Morning - AM        • Walking - W         • Head                  (0-10)                   • Name of med.              • Name of med.                 HERBAL
                         • Afternoon - PM      • Sitting - S         • Lower back            0 = no pain              • Time taken? (am/pm)       • Time taken? (am/pm)
                                                                                                                                                                                REMEDIES,
                         • Night - N           • Standing - ST       • Knees/Hips            5 = moderate pain        • How often?                • How often?
                         • All Day - A         • Bending - B         • Hand/Fingers          10= worst pain             (once daily, every 4        (once daily, every 4      SUPPLEMENTS,
                                               • Sleeping - SL       • Legs                                             hrs, before bed, etc.)      hrs, before bed, etc.)         ETC.
                                               • List Other          • Chest                                          • Level of relief           • Level of relief
                                                                     • Pelvic Area                                      None - N                    None - N
                                                                     • List other                                       Some - S                    Some - S
                                                                                                                        Great - G                   Great - G
                                                                                                                      • Time before feeling       • Time before feeling
                                                                                                                        relief?                     relief?
      M
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