My Weekly Pain Journal Template
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1Use this pain journal to record your pain, daily
MY WEEKLY PAIN JOURNAL!
activities, and your medications.!
NAME: ____________________________________!
If you are experiencing severe pain, call your
WEEK: _______ MONTH: _______ YEAR: _______
healthcare provider immediately.
!
TIME OF
ACTIVITIES
WHERE IS
LEVEL OF
1st MED!
2nd MED!
PAIN!
CAUSING
PAIN?!
PAIN SCALE
• Name of med.!
• Name of med.!
LIST
• Time taken?
• Time taken?
• Morning-AM!
PAIN!
• Head!
OF 1-10!
ADDITIONAL
(am/pm)!
(am/pm)!
• Afternoon-PM
• Lower back!
• Walking!
• 0= no pain!
MEDICATION
• How often?
• How often?
• Night-N!
• Knees/Hips!
• Sitting!
• 5= moderate
S, HERBAL
(once!
(once!
• All Day-A
• Hand/Fingers!
• Standing!
pain !
REMEDIES,
daily, every 4
daily, every 4
• Legs!
• Bending!
• 10= worst
SUPPLEMEN
hrs,!
hrs,!
• Chest!
• Sleeping!
pain
DESERT CLINIC
TS, ETC.
before bed,
before bed,
• Pelvic Area!
• List Other
etc.)!
etc.)!
• List Other
• Level of relief!
• Level of relief!
None Some
None Some
Great!
Great!
P a i n & W e l l n e s s
• Length of time
• Length of time
before feeling
before feeling
relief?
relief?
Your pain is our priority!
(760) 321-1315
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Parent category: Medical