My 
Pain Diary.
Fill in all boxes using the Numerical Scale of:

0
.....................................................
10
= 
Less
= 
More
Week Ending: .... / .... / ......
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Morning - Overall Pain Level
 
 
 
 
 
 
 
Afternoon - Overall Pain Level 
 
 
 
 
 
 
 
Evening - Overall Pain Level 
 
 
 
 
 
 
 
Physical Symptoms.
 
 
 
 
 
 
 
How well did I sleep?
 
 
 
 
 
 
 
How weak do I feel?
 
 
 
 
 
 
 
How dizzy / lightheaded do I feel? 
 
 
 
 
 
 
 
Are my bowel movements normal?
 
 
 
 
 
 
 
Is my urination output normal?
 
 
 
 
 
 
 
What are my exercise levels?
 
 
 
 
 
 
 
Cognitive / Emotional Symptoms 
 
 
 
 
 
 
 
How is my thinking ability?
 
 
 
 
 
 
 
How anxious do I feel?
 
 
 
 
 
 
 
How depressed / frustrated am I?
 
 
 
 
 
 
 
How angry / irratable am I?
 
 
 
 
 
 
 
How happy am I?
 
 
 
 
 
 
 
Possible Exacerbating Conditions 
 
 
 
 
 
 
 
Is the weather affecting me?
 
 
 
 
 
 
 
Is the humidity affecting me?
 
 
 
 
 
 
 
Have I done too much?
 
 
 
 
 
 
 
Any Comments or Notes I need to 
add go here: