At-a-Glance Pain Assessment & Daily Journal
Download and print this assessment and journal, fill it out, and discuss it with your physician.
Pain doesn’t have to be a part of daily life. If you are currently experiencing pain, talking to your physician is the first step toward finding the right treatment and getting on track. Like other medical conditions, chronic pain can be treated effectively. Sometimes it can be hard to find the right words to describe your pain or maybe you just don’t know how to get the conversation started.
Before your next physician appointment, take the time to fill out the pain assessment and journal below to help provide your physician with a snapshot of your individual pain profile. Treating pain isn’t a "one size fits all" answer, and by working with your physician you’ll find the solutions that are right for you.
Pre-Visit Pain Questionnaire
1. Where is your pain? (Take a moment to think about all the areas of your body – such as back, knees, neck, legs, head, feet, and arms.) On the diagram, shade in the areas where you feel pain, and place an X on the area that hurts the most.
2. Circle the words that describe your pain:
||pins and needles|
3. When and how did your pain begin? (Work related accident, unprompted, etc.)
4. How often do you experience pain? Circle one:
5. What time of day is your pain the worst? Circle one:
6. What would you rate your pain at its WORST in the last month on a scale from 1 to 10? (most severe being 10):
7. What would you rate your pain at its LEAST in the last month on a scale from 1 to 10? (most severe being 10):
8. What would you rate your pain on AVERAGE in the last month on a scale from 1 to 10? (most severe being 10):
9. What makes your pain BETTER?
10. What makes your pain WORSE?
11. Circle the SIDE EFFECTS or SYMPTOMS you are having:
|lack of appetite
12. What events aggravate your pain? (standing, lying down, walking, work related motions, etc.)
13. Make a list of medications – both over-the-counter, prescription and alternative therapies (herbal, etc.) – that you have taken to treat your pain.
14. How has pain interfered with your life? (i.e. general activity, mood, sleep, relationships, etc.)
15. How has pain affected your family?