crsheader Index Illustration Thumbnail image of: Pain Diary (Chart) Pain Diary

If your child has recurrent pains, please collect the following information about the pain during three bouts of pain before you make an initial or follow-up appointment. This information may be very helpful in reaching a correct diagnosis.

1. Date:

Time of day:

Place (home, school, etc.):

People present:

2. Describe the Pain

Where on the body?

How long did it last (in minutes)?

How bad (on a scale of 1 to 10 where 1 = mild, 10 = unbearable)?

What did it keep your child from doing?

3. Triggers for Pain

Thoughts (any stresses) before the pain (within 1 hour)?

Feelings (upset or fearful) before the pain (within 1 hour)?

Activities before the pain (within 2 hours):

Food eaten before the pain (within 4 hours):

4. Treatment

What did you do to make it feel better?

5. Your Observation

What do you think was the cause of the pain this time?

Written by Barton D. Schmitt, MD, author of “My Child Is Sick”, American Academy of Pediatrics Books. Published by RelayHealth.
Last modified: 1996-01-16
Last reviewed: 2010-06-02 This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Pediatric Advisor 2011.4 Index
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