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Pain Control Record
Medicines you are taking now
Pain medicines you have taken in the past
You can use a chart like this to keep a record of how well your medicine is working.
Some people call it a pain diary. Write the information in the chart below. Describe
the amount of pain you feel using the way that works best for you. You can use
words, numbers on a scale from 0 to 10, or even draw a face (see
Talking About Your Pain 1 for
examples). Take the chart with you when you visit your doctor.
| Date | Time | Describe the pain you feel | Level of
pain |
6/8
(example) | 8 a.m. | stabbing pain in side | 9 |
6/10
(example) | all day | dull ache in legs | 5 |
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Medicines you are taking now
Use this form to record all medicines - not just pain medicines - that you are taking.
This information will help your doctor keep track of all your medicines.
| Date | Medicine | Dose | How often
taken | How well is it
working? | Prescribing
doctor |
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Pain medicines you have taken in the past
Use this form to record the pain medicines you have taken in the past. It will help
your doctor understand what has and hasn't worked.
| Date | Medicine | Dose | How often
taken | Side
effects | Reason
for stopping |
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