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
Allow yourself to share your experience with this invisible illness and help yourself and others too. Share your tools, how you deal with everyday life, and gain access to information on Chronic Fatigue and Immune Dysfunction Syndrome and Fibromyalgia (CFIDS/FMS). My mission is to empower patients to take control of their health by providing my own story and experience with treatment information, quality health products, community, and advocacy.
1 comment:
GREAT form, Viv. I might have to consider doing this daily to track my pain to see if there's a pattern to my fibro-flareups. It seems they've been infrequent lately, although I still get that burning sensation in my shoulders, neck, and legs every day. Thanks for sharing!
Jenno
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