This document is a
Pain Diary Worksheet. It is not a math problem or a quiz with a single correct answer. Instead, it is a tool for you to fill out yourself to track how you are feeling.
Because this is a personal log, there is no "right" answer for me to give you. However, I can explain exactly how to use it so you can complete your homework assignment correctly.
How to Fill Out This Worksheet
1. The Date
* Look at the top right corner. Write today’s date on the line labeled "Date."
2. Mark Where It Hurts (The Blue Bodies)
* Look at the two blue figures at the top (one front, one back).
* If you have pain, draw an X or circle the spot on the body where it hurts.
*
The Code: On the left side, there is a list of letters. Next to the spots you marked, write the letter that matches your pain type:
*
S: Shooting pains (like electric shocks)
*
X: Stabbing pains (like being poked with a knife)
*
B: Burning pains (like fire or heat)
*
A: Aching pains (a dull, steady hurt)
*
T: Throbbing (pulsing pain)
*
C: Cramping (tight squeezing pain)
*
D: Dull (not sharp, just uncomfortable)
*
N: Numbness (no feeling)
*
P: Pins and needles (tingling)
3. Physical Symptoms (The Numbers 1–10)
* There are many boxes asking about your body (Sleep, Fatigue, Dizziness, Appetite, etc.).
* Each box has a scale from
1 to 10.
*
1 usually means "Good," "No Rest," or "Not affected."
*
10 usually means "High," "Very dizzy," or "Greatly affected."
*
What to do: Circle the number that matches how you feel right now. For example, if you are very tired, circle a high number (like 8, 9, or 10) under "What is my fatigue level?"
4. Mental, Cognitive, & Emotional
* These boxes ask about your feelings and thoughts (Anxious, Depressed, Angry, Happy).
* Again, circle the number from 1 to 10 that matches your mood.
* Example: If you feel very happy, circle a high number under "How happy am I?"
5. Exacerbating Conditions
*
Current Weather: Check the box that matches the weather outside (Sunny, Overcast, Foggy, Rainy).
*
Temperatures: Write if it is High or Low.
*
Stress Levels: Circle a number from 1 to 10 for your family/home stress and your job stress.
6. Medications & Notes
*
Medications taken: List any medicine you took today.
*
Notes: Use the lines at the bottom to write anything else important, like what you were doing when the pain started.
Summary for Your Homework
To finish this task, you simply need to:
1. Write the date.
2. Mark any pain spots on the blue figures.
3. Circle the numbers (1–10) that describe how you feel physically and emotionally.
4. Fill in the weather and stress levels.
5. List any medicines.
Since I cannot feel your pain or know your mood, you must fill in the specific numbers and marks based on your own experience today.
Parent Tip: Review the logic above to help your child master the concept of pain diary worksheet.
