Daily Pain Monitor

• Document No.

• Pain Record for:

• Add days with this bar.

Day

• Select date

  Date

• Pain Location

  Select Neck Right Shoulder Left Shoulder Knees General Body Both Shoulders

  • Neck
  • Right Shoulder
  • Left Shoulder
  • Knees
  • General Body
  • Both Shoulders

• Pain Level 1 = low 5 = extreme

  5

  4

  3

  2

  1

• If 3, 4 or 5 add possible reason: i.e. lifting, walking, driving etc

• Add another pain location if not adequately covered above.

Pain Location

• Pain Location

  Select Neck Right Shoulder Left Shoulder Knees General Body Both Shoulders

  • Neck
  • Right Shoulder
  • Left Shoulder
  • Knees
  • General Body
  • Both Shoulders

• Pain Level 1 = low 5 = extreme

  5

  4

  3

  2

  1

• If 3, 4 or 5 add possible reason: i.e. lifting, walking, driving etc

Next Day