Ticked Bucket List Daily Pain Flare-up Monitoring Chart Ticked Bucket List Daily Pain Flare-up Monitoring Chart Date and Time: Pain Level (0-10): 0 = No pain, 10 = Worst pain possible. Pain Areas: Lower Back Neck Chest Abdomen Pelvis Right Shoulder Right Arm Right Forearm Right Wrist Right Fingers Right Hip Right Thigh Right Leg Right Foot Right Toes Right Side of Body Left Shoulder Left Arm Left Forearm Left Wrist Left Fingers Left Hip Left Thigh Left Leg Left Foot Left Toes Left Side of the Body Head Upper Jaw Lower Jaw Right Side of the Face Left Side of the Face Whole Body Pain Pattern: Old Pain New Pain Both Old and New Pain Red Flags: Weight Loss Fever Loss of Organ Function Breathlessness Injuries like Fractures None Duration: Triggers: Medications/Treatments Used: Pain Relief Outcome: Excellent and adequate Some short-lasting pain relief Pain relief but with intolerable side effects No Pain relief No pain relief only side effects Functional Outcome: All usual activities Only activities of self-care Bed-ridden Mood and Mental State: Normal mood Depressed Anxious Cranky Frustrated Sleep: Good sleep quality and quantity Disrupted sleep Do you require Emergency Medical Attention? Yes No Have you checked any Red Flag Symptoms or New Pain? Yes (you need urgent medical evaluation) No Download PDF Save Data Share via Email Share via WhatsApp Print
