Tuesday, December 15, 2009
Name the area(s) that have pain: Hip, Back, Right Leg
Pain intensity: 4
Physical Symptoms:
Overall Morning Pain Level: (
9:am) 1-10 / 2
How Well Did You Sleep: 1-10 / (5) 4 ½ hrs.
You Woke Up Feeling: 1-10 / (7)
Overall Afternoon Pain Level: (Noon):
1-10 / (2)
What is your fatigue level: 1-10 / (2)
How is your appetite: 1-10 / (5)
How is your walking ability: 1-10 / (6)
Overall Evening Pain Level: (
7pm) 1-10 / (3)
What is your fatigue level: 1-10 / (5)
How is your appetite: 1-10 / (5)
How is my walking ability: 1-10 / (6)
Afternoon Nap: none
Mental, Cognitive & Emotional:
How is my ability to think: 1-10 / (8)
How anxious do I feel: 1-10 / (3)
How depressed do I feel: 1-10 / (2)
How angry do I feel: 1-10 / (0)
How irritable am I: 1-10 / (2)
How happy am I: 1-10 / (7)
How is my relationships with others affected: 1-10 / (0)
How is my enjoyment of life affected: 1-10 / (2-3)
Exacerbating Symptoms:
Family/Home Stress Level: 1-10 / (2)
Job stress level: 1-10 / (0)
Other: 1-10 / (4) (Blue Cross invoice)(Holidays)
Current weather conditions: cloudy 35-40 degrees
Medications:
30mg morphine(s) 2pm. – 10pm.
10/650mg vicoden(s) -.6pm – 12pm
Overall day : 7
