B10. Pain management log

Pain management log for:
_____________________________________________________________
Please use this pain assessment scale to fill out your pain
control log.

|_____|_____|_____|_____|_____|_____|_____|_____|_____|______|
|     |     |     |     |     |     |     |     |     |      |
0     1     2     3     4     5     6     7     8     9     10
No                                                        Worst
pain                                                       pain

 _____________________________________________________________
|Date | Time |  How    | Medicine or |   How   | Activity at  |
|     |      |severe is|  non-drug   |severe is| time of pain |
|     |      |the pain?| pain control| the pain|              |
|     |      |         |   method    |after one|              |
|     |      |         |             |   hour  |              |
|_____|______|_________|_____________|_________|______________|
|_____|______|_________|_____________|_________|______________|
|_____|______|_________|_____________|_________|______________|
|_____|______|_________|_____________|_________|______________|
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