A diary/log used to rate the effectiveness of the (or each of the) medications you may be using for your pain.

 

 
To keep a record of your pain treatment effectiveness you can print the form and complete it at your leisure. Use one form for each medication you are taking.
Record the name of the medication in the box provided. Under the day of the week record the time you took the medication. In the dosage row, record how much medication you took. In the pain rating rows enter a number that reflects your pain level (0=no pain, 10=worst pain ever). List any side effects of the medication and questions for your health care provider in the space provided.
 Name:
 Date:
 

 

 Name of medication:
Record time medication was taken

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Record dosage (amount) of medication taken

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 Rate your pain level before medication
 (0=no pain     10=worst pain ever)

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Rate your pain level after medication
 (0=no pain     10=worst pain ever)

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Request a Refill

1 + 8 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.