Wednesday, Jan. 13, 2010
Name the area(s) that have pain: Hip, Back, Right Leg, Body
Pain intensity: 4
Physical Symptoms:
Overall Morning Pain Level: (9:am) 1-10 / (3 )
How Well Did You Sleep: 1-10 / ( 3) 4 hrs.
You Woke Up Feeling: 1-10 / (4 )
Overall Afternoon Pain Level: (Noon): 1-10 / ( 3)
What is your fatigue level: 1-10 / ( 7)
How is your appetite: 1-10 / (0 )
How is your walking ability: 1-10 / (5 )
Overall Evening Pain Level: (7pm) 1-10 / (3 )
What is your fatigue level: 1-10 / (7 )
How is your appetite: 1-10 / (1 )
How is my walking ability: 1-10 / ( 5)
Afternoon Nap: none
Mental, Cognitive & Emotional:
How is my ability to think: 1-10 / (7 )
How anxious do I feel: 1-10 / ( 0)
How depressed do I feel: 1-10 / (0 )
How angry do I feel: 1-10 / ( 0)
How irritable am I: 1-10 / (2 )
How happy am I: 1-10 / (6 )
How is my relationships with others affected: 1-10 / (1 )
How is my enjoyment of life affected: 1-10 / (3 )
Exacerbating Symptoms:
Family/Home Stress Level: 1-10 / ( 0)
Job stress level: 1-10 / (0 )
Other: 1-10 / (3 )Blue Cross ( )
Current weather conditions: 12 degrees
Medications:
30mg morphine(s) 5pm. –
10/650mg vicoden(s) 5pm – 9pm
Overall day : 7
