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Please feel free to print this and use it as a pain journal. Daily Journal Worksheet Date:_________
Mood:_____________________________________________________________________________
What I did Today:____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How I Felt Today:____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Pain Triggers:_______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Positive Thinking:____________________________________________________________________
__________________________________________________________________________________
1) Worst pain experienced during last 24 hours
•|___|___|___|___|___|___|___|___|___|___|•
0 10
2) Least pain experienced during last 24 hours
•|___|___|___|___|___|___|___|___|___|___|•
0 10
3) Average pain experienced during last 24 hours
•|___|___|___|___|___|___|___|___|___|___|•
0 10
What medications taken for pain etc.?:_____________________________________________________
__________________________________________________________________________________
How much relief said medications provide?
•|___|___|___|___|___|___|___|___|___|___|•
0% 100%
How much during the last 24 hours has pain affected : 0= Does not interfere 10=Completely interferes
A) General activity •|___|___|___|___|___|___|___|___|___|___|•
0 10
B) Mood •|___|___|___|___|___|___|___|___|___|___|•
0 10
C) Walking ability •|___|___|___|___|___|___|___|___|___|___|•
0 10
D) Normal work including both work outside the home and housework •|___|___|___|___|___|___|___|___|___|___|•
0 10
E) Relationships with others •|___|___|___|___|___|___|___|___|___|___|•
0 10
F) Sleep
•|___|___|___|___|___|___|___|___|___|___|•
0 10
G) Enjoyment of Life
•|___|___|___|___|___|___|___|___|___|___|•
0 10
Morning Overall Pain Level
•|___|___|___|___|___|___|___|___|___|___|•
0 10
Afternoon Overall Pain Level
•|___|___|___|___|___|___|___|___|___|___|•
0 10
Evening Overall Pain Level
•|___|___|___|___|___|___|___|___|___|___|•
0 10
Restorative Sleep
•|___|___|___|___|___|___|___|___|___|___|•
0 Restorative Sleep 10 No Rest
Fatigue Level
•|___|___|___|___|___|___|___|___|___|___|•
0 Not tired 10 Exhaustion
Weakness
•|___|___|___|___|___|___|___|___|___|___|•
0 Not weak 10 Extremely weak
Dizziness
•|___|___|___|___|___|___|___|___|___|___|•
0 Not dizzy 10 Extremely dizzy
Eyesight
•|___|___|___|___|___|___|___|___|___|___|•
0 No vision prob. 10 Barely focusing
Elimination
•|___|___|___|___|___|___|___|___|___|___|•
0 Constipation 10 Diarrhea
Urination
•|___|___|___|___|___|___|___|___|___|___|•
0 Good Poor 10 Worst
Hearing
•|___|___|___|___|___|___|___|___|___|___|•
0 Good 10 Worst
Walking
•|___|___|___|___|___|___|___|___|___|___|•
0 Good 10 Can barely walk
Can I handle complex problems at this time?
•|___|___|___|___|___|___|___|___|___|___|•
0 Clear 10 Huh?
Anxiety Level
•|___|___|___|___|___|___|___|___|___|___|•
0 No fear 10 Very scared
Depression
•|___|___|___|___|___|___|___|___|___|___|•
0 Not depressed 10 Extremely down
Anger
•|___|___|___|___|___|___|___|___|___|___|•
0 Anger, what's that? 10 Outta my face!
Irritability
•|___|___|___|___|___|___|___|___|___|___|•
0 Smiles 10 Snarling, growling, hissing
Happiness
•|___|___|___|___|___|___|___|___|___|___|•
0 Doing the happy dance 10 Uncontrollable tears
Indoor Temp:________________
Outdoor Temp:_______________
Pollen Count:________________
Mold/Mildew Count:__________
Barometric Pressure:___________ Steady Rising Falling
Humidity:___________________
Sky is:
Sunny Partly Sunny Cloudy
Weather Condition:
Fog Light Rain Rain Heavy Rain Flurries Snow Blizzard
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DISCLAIMER All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician The staff specifically disclaim all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site. If you have any question or comments, please contact: Wayney Wayney built and maintains the site so please contact her with issues pertaining to missing pages, broken links, etc. Please feel free to contact me with comments about the content. FAIR USE NOTICE: This
site may contain copyrighted material, the use of which has not always been
specifically authorized by the copyright owner. I am making such material
available in our efforts to educate patients and no income is generated from
such use of the copyrighted material. The copyrights are owned by the
respective companies, organizations, publications, individuals. We make no
claim to the copyright of the material copyrighted by others. I have included
the full text of the article rather than a simple link because I have found
that links frequently go "bad" or change over time. The material on this site
is distributed without fee or payment of any kind to those who have expressed
a prior interest in receiving the included information for research and
educational purposes. If you wish to use copyrighted material from this site
for purposes of your own that go beyond 'fair use', you must obtain permission
from the copyright owner. All site work and other content © Waynette Porter, unless otherwise specified. Please feel free to share content provided credit is given to the author.
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