Viv's tips: Form to use to Track Your Pain

I have created a form to help you keep a record of your pain. Take it along with you when you visit your doctor. Try printing several copies and try to fill one out daily. I have tried to make it simple to complete. I know it is difficult to write out everything.

DAILY JOURNAL FOR TRACKING YOUR PAIN


Full Name _______________
Date ________

What time of the day do you feel your pain?

____When I wake up in the morning ____Throughout the day
____At night ____All of the above ____Other

COMMENTS:
________________________________________________________
________________________________________________________
________________________________________________________

What activities caused your pain?

_____Walking_____Bending_______Going up and down stairs
_____Running_____Taking a bath_____Stretching____Exercise
_____Completing simple household chores____Other

COMMENTS:
________________________________________________________
________________________________________________________
________________________________________________________

Where did you feel the pain?

___Hands ___Fingers___Arms___Shoulders___Neck___Waist
___Abdomen____Ribcage___Legs___Feet___Toes___Thighs
___Knees____Head___Breasts___Hips____Ankles____Calf
___Other

COMMENTS:
________________________________________________________
________________________________________________________
________________________________________________________

Do you get any burning sensations?
___Yes___No___Sometimes

If so, Where?

___Hands ___Fingers___Arms___Shoulders___Neck___Waist
___Abdomen____Ribcage___Legs___Feet___Toes___Thighs
___Knees____Head___Breasts___Hips____Ankles____Calf
___Other

COMMENTS:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Do you get any tingling or numbness? If so, Where?

___Hands ___Fingers___Arms___Shoulders___Neck___Waist
___Abdomen____Ribcage___Legs___Feet___Toes___Thighs
___Knees____Head___Breasts___Hips____Ankles____Calf
___Other


Rate the level of pain: (1=mild, 5=moderate, 10=severe)
___1 ____5 ____10 _____Other

COMMENTS:
_______________________________________________________
_______________________________________________________
_______________________________________________________

What medication are you taking to treat your pain?

Medication/Dosage_________________________________________
_______________________________________________________
_______________________________________________________

When Taken ______AM/PM
Relief? ____Yes____No____Some

How long did the medication take before it worked?
___Minutes___Hour _____Hours_____Not at all

COMMENTS:
_______________________________________________________
_______________________________________________________
_______________________________________________________

I pray and hope this form helps out someone.

Take care,

FibroViv