Pain And Symptom Diary Template

ADVERTISEMENT

Pain & symptom diary
Keeping a record of your pain and symptoms can help you
and your doctor to manage your symptoms, could help
with a diagnosis and also could be used when submitting
information for evidence e.g. when claiming for benefits,
for work or for school/university.
This first part of this form is a list of questions. Over the page is a diary for one week.
Please copy this diary if you need to record your symptoms for more than one week.
Please answer as honestly as you can – your answers will be invaluable for your
doctor. Don’t just answer ‘yes’ or ‘no’ but try to provide as much information as you
can. You may not think that it is relevant – but it could be.
General questions
Date of last period:
1.
What age were you when you started your periods?
2.
Are your periods regular e.g. every month? Y/N
If not, how regular are they?
3.
How long does your typical period last?
4.
Would you describe it as light, medium, heavy or very heavy?
5.
Do you bleed between periods?
Pain
1.
Do you get pain during your period?
2.
Do you get pain at other times of the month? Y/N
If so, when?
3.
Where do you get this pain? Can you mark on the diagram overleaf exactly
where you experience pain? Please do include back, leg and chest pain if
applicable
Registered Charity No. 1035810. Company Limited by Guarantee No: 2912853

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Life
Go
Page of 3