Pain And Symptom Diary Template Page 3
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1
2
3Do you have any other
symptoms? e.g.
Did you take or do
Week
Are you
How does it feel** and
bloating, bleeding,
anything to help with
beginning
on your
Describe your pain*
how long does it last?
bowel or urinary
the pain or symptoms?
What affect did it have
DD / MM / YY
period?
and where it is
e.g. 3 hours
problems
If so, what did it help?
on you?***
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
*
Please rate your pain on a scale of 1-10. Where 1 = tolerable and 10 = the worst pain imaginable
** Please use the words listed on question 6 under “pain”, or add your own
*** Please state whether these symptoms affected your work, education, relationships, social activities, sleep, exercise, food intake, sex life, stress levels, quality of life that day
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Parent category: Life