two week pain diary
week 1 dates:
day
&
time
1: b'kfast
lunch
tea
bedtime
2: b'kfast
lunch
tea
bedtime
3: b'kfast
lunch
tea
bedtime
4: b'kfast
lunch
tea
bedtime
5: b'kfast
lunch
tea
bedtime
6: b'kfast
lunch
tea
bedtime
7: b'kfast
lunch
tea
bedtime
pain index:
week 2 dates:
pain index:
pain
medicine comment day
pain
medicine comment
intensity
or
&
intensity
or
0-5
tablets
time
0-5
tablets
8:
9:
10:
11:
12:
13:
14:
Four times daily record the current intensity of your pain using the 0 - 5 scale: 0 = No pain. 1 = Low
level pain entering awareness only when I pay attention to it. 2 = Pain exists, but can be ignored at
times. 3 = Pain exists, but I can continue performing all the tasks I normally would. 4 = Very severe pain
that makes it difficult to concentrate, but allows me to perform tasks of an undemanding nature. 5 =
Intense, incapacitating pain. Each week's "Pain Index" is calculated from the sum of the 28 weekly pain
intensity ratings divided by 7. Note too the name and number of any medicine or tablets you took during
each time period. If relevant other brief notes on possible aggravating or relieving factors, and causes can
be included in the comment column if you feel they would be helpful in understanding your pain.