Pain Control Record
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 page 7 for examples). Take the chart with you when you visit your doctor.
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.
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.
