"Pain Level Log Template - Dr. Colleen Blanchfield"

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Dr. Colleen Blanchfield
11490 Commerce Park Drive Suite 420
Reston, Virginia 20191
Name: ___________________________________
Pain Log
Ph - 703-481-9111 F - 703-707-8657
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
Description of Pain
Pain Scale
Key
1. _____________________________
0
6
No pain even when focused on
PPA and IWA >90 of time; MR
IWA - Interferes with Activities
2. _____________________________
1
7
Pain when focused on 50% of time
PPA, UTF, 50% SB; MR
PPA - Pain Present Always
3. _____________________________
2
8
Pain present 50% of time; doe not IWA
PPA, UTF, >50% SB; MR
MR - Medication Required
4. _____________________________
3
9
Pain present 50% of time; doe not IWA
PPA, UTF, 100% TSB; some ROP; MR
UTF - Unable to Function
5. _____________________________
4
10
PPA and IWA <50% of time; MR
PPA, UTF, 100% TSB, no ROP; MR
TSB - Time Spent in Bed
5
PPA and IWA 75 of time; MR
ROP - Relief of Pain
Dr. Colleen Blanchfield
11490 Commerce Park Drive Suite 420
Reston, Virginia 20191
Name: ___________________________________
Pain Log
Ph - 703-481-9111 F - 703-707-8657
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
Description of Pain
Pain Scale
Key
1. _____________________________
0
6
No pain even when focused on
PPA and IWA >90 of time; MR
IWA - Interferes with Activities
2. _____________________________
1
7
Pain when focused on 50% of time
PPA, UTF, 50% SB; MR
PPA - Pain Present Always
3. _____________________________
2
8
Pain present 50% of time; doe not IWA
PPA, UTF, >50% SB; MR
MR - Medication Required
4. _____________________________
3
9
Pain present 50% of time; doe not IWA
PPA, UTF, 100% TSB; some ROP; MR
UTF - Unable to Function
5. _____________________________
4
10
PPA and IWA <50% of time; MR
PPA, UTF, 100% TSB, no ROP; MR
TSB - Time Spent in Bed
5
PPA and IWA 75 of time; MR
ROP - Relief of Pain
Dr. Colleen Blanchfield
11490 Commerce Park Drive Suite 420
Reston, Virginia 20191
Name: ___________________________________
Pain Log
Ph - 703-481-9111 F - 703-707-8657
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
10
9
8
7
Level
6
of
5
Pain
4
3
2
1
0
Time of Day
AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS AM 12N PM HS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day of the week
Date :
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
____ /____
Description of Pain
Pain Scale
Key
1. _____________________________
0
6
No pain even when focused on
PPA and IWA >90 of time; MR
IWA - Interferes with Activities
2. _____________________________
1
7
Pain when focused on 50% of time
PPA, UTF, 50% SB; MR
PPA - Pain Present Always
3. _____________________________
2
8
Pain present 50% of time; doe not IWA
PPA, UTF, >50% SB; MR
MR - Medication Required
4. _____________________________
3
9
Pain present 50% of time; doe not IWA
PPA, UTF, 100% TSB; some ROP; MR
UTF - Unable to Function
5. _____________________________
4
10
PPA and IWA <50% of time; MR
PPA, UTF, 100% TSB, no ROP; MR
TSB - Time Spent in Bed
5
PPA and IWA 75 of time; MR
ROP - Relief of Pain
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