"Pain Diary Template - We Are Macmillan Cancer Support"

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Pain
DiArY
How to use your pain diary
You may want to pull out this pain diary and photocopy it,
so you can use it more than once. Remember to photocopy
the back page as well.
1. Begin by noting down the date when you use a new diary.
You can fill in the diary as often as you need to. If your pain isn’t
well controlled, you may want to fill it in every 1–2 hours, but if it’s
better controlled, you can fill it in every 4–6 hours.
2. Note where the pain is on your body – you can use the body
pictures on the back page of the diary. It could be in one area
or in multiple areas.
3. Describe what the pain feels like. See the back page of the
diary for words you can use to describe your pain.
4. Rate the level of pain on a scale of 0 to 10, where 0 means no
pain and 10 means severe pain (see the back page of the diary).
5. Note down which medicines or pain control methods you used,
and anything that made the pain better or worse.
All of this information will help you and you healthcare team find
the best pain control methods for you.
Pain
DiArY
How to use your pain diary
You may want to pull out this pain diary and photocopy it,
so you can use it more than once. Remember to photocopy
the back page as well.
1. Begin by noting down the date when you use a new diary.
You can fill in the diary as often as you need to. If your pain isn’t
well controlled, you may want to fill it in every 1–2 hours, but if it’s
better controlled, you can fill it in every 4–6 hours.
2. Note where the pain is on your body – you can use the body
pictures on the back page of the diary. It could be in one area
or in multiple areas.
3. Describe what the pain feels like. See the back page of the
diary for words you can use to describe your pain.
4. Rate the level of pain on a scale of 0 to 10, where 0 means no
pain and 10 means severe pain (see the back page of the diary).
5. Note down which medicines or pain control methods you used,
and anything that made the pain better or worse.
All of this information will help you and you healthcare team find
the best pain control methods for you.
pain diArY
Keeping a record of your pain will help you discuss it with your doctors and nurses.
date
/
/
Photocopy this diary before you fill it in so that you can use it as often as you need to. If you
have pain in more than one place, you may wish to use an extra copy of this diary.
Level of pain
Where is
What is the
Medicines/pain
What makes
What makes
(where 0=none
Time
the pain?
pain like?
control used?
the pain better?
the pain worse?
and 10=severe)?
1am
0
5
10
2am
0
5
10
3am
0
5
10
4am
0
5
10
5am
0
5
10
6am
0
5
10
7am
5
0
10
8am
0
5
10
9am
0
5
10
10am
0
5
10
11am
0
5
10
12pm (noon)
0
5
10
1pm
0
5
10
2pm
0
5
10
3pm
5
0
10
4pm
5
0
10
5pm
0
5
10
6pm
0
5
10
7pm
0
5
10
8pm
0
5
10
9pm
5
0
10
10pm
5
0
10
11pm
0
5
10
12am (midnight)
0
5
10
Where is the pain?
Is it in one part
of your body or
in more than
one place?
You can use the
diagrams on the
right to mark where
your pain is.
If you have more
than one area of
pain, you may want
to label them (for
example, A, B, C).
front
back
What is the pain like?
Use any of the following words that best describe your pain:
• aching
• dragging
• numb
• smarting
• biting
• dull
• penetrating
• sore
• blunt
• excruciating
• piercing
• spreading
• burning
• frightful
• pins and
• stabbing
• cold
• gnawing
needles
• stinging
• comes
• hot
• pricking
• tender
and goes
• intense
• radiating
• throbbing
• constant
• nagging
• scratchy
• tingling
• crushing
• nauseating
• sharp
• tiring
• cutting
• niggling
• shooting
• unbearable.
Numbered pain scale
5
0
10
How bad is your pain? If you measured it on a scale of 0 to 10,
how would you rate it (where 0 is no pain and 10 is the worst pain
you’ve ever had)?
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