Pain Assessment Checklist

Discussion in 'Fibromyalgia Main Forum' started by JLH, Jun 7, 2006.

  1. JLH

    JLH New Member


    When discussing your pain with your doctor, he needs to understand what type of pain that you have as well as how it affects your daily life.

    The pain you are feeling can be hard to describe. This checklist may help your doctor identify what type of pain you are feeling and what your options are for managing your pain.

    In order to help you describe the pain to your doctor, complete the checklist below and share it with your doctor.

    1. I would describe my pain as:
    (Check all that apply.)
    __ Pins and needles
    __ Stabbing/shooting
    __ Burning
    __ Aching/throbbing
    __ Numb
    __ Sharp
    __ Uncomfortable numbness and tingling sensations
    __ Other, please describe __________

    2. My pain worsens:
    (Check all that apply.)
    __ In the morning
    __ In the afternoon
    __ In the evening
    __ While sleeping

    3. I would rate my pain as:
    (Use a scale of 0 to 10, with 0 being no pain, and 10 being the worst possible pain)

    For example:
    0 - no pain at all
    2 - hurts a little bit
    4 - hurts a little more
    6 - hurts even more
    8 - hurts a whole lot
    10 - hurts the worst

    4. My pain interferes with my ability to:
    (Check all that apply.)
    a. Go up or down stairs. Yes or No
    b. Get in or out of a car. Yes or No
    c. Get in or out of bed. Yes or No
    d. Play with kids/grandkids. Yes or No
    e. Perform heavy chores Yes or No
    f. Sleep Yes or No
    g. Perform daily activities such as:
    shopping Yes or No
    cooking Yes or No
    vacuuming Yes or No
    bathing Yes or No
    dressing Yes or No
    napping Yes or No
    walking Yes or No
    standing Yes or No

    5. I am taking, or have taken, medication for my pain:
    __ Yes
    __ No

    6. The medication(s) that I current take, or have taken, for my pain:
    __ Help(s) me with my pain
    __ Do(es) not help me with my pain
    __ Help(s) for a time, then wears of too soon

    7. I have been diagnosed with:
    __ Diabetes
    __ Shingles
    __ Fibromyalgia
    __ Lupus
    __ Arthritis (indicate what type: ________)

    The doctors need to:
    • Understand that we need relief.
    • That our stabbing, shooting, burning pain affects us 24/7.
    • Provide us tips on managing our pain, as well as fatigue.

    Pain Tracking Diary:
    • Download, print, and fill out the diary. It will help you learn more about your pain and what triggers it. And, it will help your doctor assess how well your current treatment is working.
    • Go to to find the Pain Tracking Diary.

    Taking a Pain Diary to the doctor with you each visit will show him/her about your pain, too.

  2. cinnveet

    cinnveet New Member

    i tried the web site as i am really interested in tracking my pain for when i see the dr. and the web site gives an error.???

  3. JLH

    JLH New Member


    I'm sorry about getting an error message. I tried the same web address and got an error message also.

    I noticed that it was showing up instead of the So I tried the and it didn't come up either.

    So ... I went to Google and put in Lyrica, and the same info on showed up so I clicked on it and ended up getting!!

    I could not see where the Pain Tracking Diary was, so I put it in the search box and found it. When I clicked on it, however, it came up an error. Ugh!!!

    So .... I emailed Pfizer and asked them what their problems were!!! If I get a reply, I'll post it on here.

    Sorry about all the trouble.


    Edited ...
    They do have a toll-free phone number to call for questions:
    1-866-459-7422. Maybe they would have a hard copy to send you!
    [This Message was Edited on 06/07/2006]
  4. cinnveet

    cinnveet New Member


    Thank you for going thru all that. I really appreciate it.

    I will give them a call. I will also let you know as well as others if they do have a hard copy.

    Again that was very kind of you to go that extra mile looking for the diary.

    God Bless,
  5. JLH

    JLH New Member

    Pfizer emailed me back today and said they could not help me with what was wrong with THEIR site!!! Go figure!
  6. mrsjethro

    mrsjethro New Member

    Try this one and see if it is what you were looking for??

    I googled for lyrica for nerve pain, diary. Took me a couple of pages to get to it. Maybe this is it. Was it a pdf format? I didn't go that far.

    OH!!!! Here it is
    [This Message was Edited on 06/10/2006]

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