Aware-RSD

Pain Diaries

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"Keep For Your Records"
DOCTOR'S VISIT

Patient's Name____________________________
Doctor___________________________________
Date______________________Time__________________
Office____________________________

Comments: Who attended appt. with you, if no one goes with you take
a tape recorder, so you can remember what was said, who did you talk
with any of the office staff, did you make new friends while
waiting, etc.:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

HOW I FEEL
TODAY:________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________


ON SCALE OF 1 TO 10
1 BEING ZERO PAIN AND
10 BEING UNTOLERABLE
RATE THE NEXT 2 QUESTIONS BELOW

Pain Before Appointment:
ZERO * Bothersome * Uncomfortable * Consuming * Untolerable
|__________|___________|_____________|__________|__________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Pain After Appointment:
ZERO * Bothersome * Uncomfortable * Consuming * Untolerable
|__________|___________|_____________|__________|__________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

How Tired are You?:
Fully Rested * Rested * Tired * Exhausted *No Sleep
|__________|_______|________|_________|_________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

How You are Feeling Emotionally?:
Happy * Stressed * Irritable * Depressed * Can't Cope
|________|________|_________|_________|__________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

PHYSICAL CONDITION DOCTOR NOTED UPON EXAM:
Insomnia?: Yes_____ No_____
Depression?: Yes_____ No______
Skin Rash?: Yes______ No______
Cold or Hot Extremity?: Yes_____ No______
Tingling Pain?: Yes_____ No______
Spasms?: Yes_____ No______
Stabbing Pain?:  Yes______ No_____
Burning Pain?: Yes_____ No______
Swelling?: Yes_____ No_____
Where:________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
More/Less than last appt?_____________

Temp. Changes?: Yes____ No____
Where:________________________________________________________
______________________________________________________________
More/Less than last appt?_____________

Skin Discoloration?: Yes___ No___
Where:________________________________________________________
______________________________________________________________
More/Less than last appt?_____________

Difficulty Walking?: Yes___ No___
Why:__________________________________________________________
______________________________________________________________
More/Less than last appt?_____________

Difficulty Using Limbs?: Yes____ No____
Which:________________________________________________________
______________________________________________________________
More/Less than last appt?_____________

MEDICATIONS YOU TAKE BEFORE
EXAM:_________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

MEDICATIONS GIVEN AFTER
EXAM:_________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 

PATIENT COMPLAINED OF (Can be filled in by Patient before exam but
initialed by doctor at end of exam):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

DOCTOR'S COMMENTS/RECOMMENDATIONS:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

TODAY'S TREATMENTS:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
MISCELLANEOUS: (Meds,dosage,changes in Rx):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

WAITING AUTHORIZATION FOR:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

NEXT SCHEDULED EXAM: __________________  NEXT SCHEDULED
TREATMENT:__________________________________________________
_______________________________________________________________
WHAT ARE THE
TREATMENTS:_________________________________________________
_______________________________________________________________
_______________________________________________________________

SIGNED:
Patient:___________________________Doctor:_______________________
Witness:____________________________

 

B1. Brief Pain Inventory (Short Form)

Study ID#_________________        Hospital#________________
                                                   Do not write above this line
                                    Date:____/____/____
                                    Time:______________
                                    Name:______________________________________________________
                                               Last               First           Middle Initial
                                    
                                    1) Throughout our lives, most of us have had pain from time to 
                                       time (such as minor headaches, sprains, and toothaches). 
                                       Have you had pain other than these everyday kinds of pain
                                       today?    
                                                      1. yes             2. no
                                    
                                    2) On the diagram, shade in the areas where you feel pain. Put
                                       an X on the area that hurts the most.
                                    
                                    
                                    
                                    3) Please rate your pain by circling the one number that best
                                       describes your pain at its WORST in the past 24 hours.
                                    
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9     10
                                    No                                              Pain as bad as
                                    pain                                            you can imagine
                                    _____________________________________________________________
                                    
                                    4) Please rate your pain by circling the one number that best
                                       describes your pain at its LEAST in the past 24 hours.
                                    
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9     10
                                    No                                              Pain as bad as
                                    pain                                            you can imagine
                                    _____________________________________________________________
                                    
                                    5) Please rate your pain by circling the one number that best
                                       describes your pain on the AVERAGE.
                                    
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9     10
                                    No                                              Pain as bad as
                                    pain                                            you can imagine
                                    _____________________________________________________________
                                    
                                    6) Please rate your pain by circling the one number that tells
                                       how much pain you have RIGHT NOW.
                                    
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9     10
                                    No                                              Pain as bad as
                                    pain                                            you can imagine
                                    _____________________________________________________________
                                    
                                    7) What treatments or medications are you receiving for your
                                       pain?
                                    _____________________________________________________________
                                    
                                    8) In the past 24 hours, how much RELIEF have pain treatments
                                       or medications provided? Please circle the one percentage
                                       that most shows how much.
                                    
                                    _____________________________________________________________
                                    0%    10%   20%   30%   40%   50%   60%   70%   80%   90%  100%
                                    No                                                     Complete
                                    relief                                                   relief   
                                    _____________________________________________________________
                                    
                                    
                                    9) Circle the one number that describes how, during the past 24
                                       hours, PAIN HAS INTERFERED with your:
                                    
                                       A.  General Activity:
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       B.  Mood
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       C.  Walking ability
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       D.  Normal work (includes both work outside the home and
                                           housework)
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       E.  Relations with other people
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       F.  Sleep
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                       G.  Enjoyment of life
                                    _____________________________________________________________
                                    0     1     2     3     4     5     6     7     8     9    10  
                                    Does not                                            Completely
                                    interfere                                           interferes
                                    _____________________________________________________________
                                    
                                    Source: Pain Research Group, Department of Neurology,
                                    University of Wisconsin-Madison.
                                    Used with permission. May be duplicated and used in 
                                    clinical practice.

 

B2. Initial Pain Assessment Tool

                                
                                              Date:________________
                                    
                                    Patient's name:_______________________ Age:________ Room:_______
                                    
                                    Diagnosis:____________________________ Physician:_______________
                                                                               Nurse:_______________
                                    
                                       I. Location: Patient or nurse marks drawing
                                    
                                    Drawings of Figures in different positions
                                    
                                    II. Intensity: Patient rates the pain. Scale used: ___________
                                    Present:__________________________________________________
                                    Worst pain gets:__________________________________________
                                    Best pain gets:___________________________________________
                                    Acceptable level of pain:_________________________________
                                    
                                    III. Quality: (Use patient's own words, e.g., prick, ache, burn,
                                    throb, pull, sharp)
                                    __________________________________________________________
                                    
                                    IV. Onset, duration, variations, rhythms:_____________________
                                    __________________________________________________________
                                    
                                    V. Manner of expressing pain:________________________________
                                    
                                    VI. What relieves the pain?___________________________________
                                    
                                    VII. What causes or increases the pain?________________________
                                    
                                    VIII. Effects of pain: (Note decreased function, decreased quality
                                    of life.)
                                    Accompanying symptoms (e.g., nausea)_______________________
                                    Sleep______________________________________________________
                                    Appetite___________________________________________________
                                    Physical activity__________________________________________
                                    Relationship with others (e.g., irritability)______________
                                    Emotions (e.g., anger, suididal, crying)___________________
                                    Concentration______________________________________________
                                    Other______________________________________________________
                                    
                                    IX. Other comments:___________________________________________
                                    
                                    X. Plan:_____________________________________________________
                                    __________________________________________________________
                                    
                                    Note: May be duplicated and used in clinical practice
                                    Source: McCaffery and Beebe, 1989. Used with permission.
                                    
 
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: 
 
 
 
 
 
 

EMERGENCY TREATMENT INFORMATION:

 I am experiencing extreme pain resulting from my Chronic Pain condition(s). With this form is a letter,

verifying my diagnosis and treatment by my doctor presently.

 

REGISTRATION INFORMATION:

 

_____________________________________________________________________________

Full Name

_____________________________________________________________________________

Address City State Zip Code

_____________________________________________________________________________

Home Phone Office Phone

_____________________________________________________________________________

Employer

_____________________________________________________________________________

Emergency Contact Relationship Phone Number

 

TREATMENT INFORMATION:

 

On a scale of 1-10, currently my pain is ________.

To treat this pain that my condition(s) causes me, the following medications have been used:

 

______________________________________________________________________________

Medication/ Dosage/ Time Taken/

______________________________________________________________________________

Medication/ Dosage/ Time Taken/

______________________________________________________________________________

Medication/ Dosage/ Time Taken/

 

 

OTHER MEDICATIONS:

 

______________________________________________________________________________

Medication Dosage Time Taken

______________________________________________________________________________

Medication Dosage Time Taken

_____________________________________________________________________________

Medication Dosage Time Taken

 

KNOWN ALLERGIES: _______________________________________________________________

 

______________________________________________________________________________

Signature Date

This form provided by Our Chronic Pain Mission http://cpmission.com/