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