DAIL Y P AIN JOURNAL
Date:_______________
Time
Activity
Pain Rating
Pain Medication(s)
Other Pain Relief
(0-10)
Taken (Yes/No)
Methods Used (list)
a.m.
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
p.m.
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00

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Date/
Severity of Fatigue 0-10 (where
Level of Interference with Daily
0 means no fatigue and 10 means the
Activities 0-10
Anything Done to Relieve Fatigue
Time
worst fatigue imaginable
(e.g. grooming & shopping)
FATIGUE
JOURNAL
Factors that Make Fatigue Worse (emotional & physical):
Factors that Improve Symptoms of Fatigue:

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