Pain Diary
Severity of pain 0 1 2 3 4 5
Patient Name: .....................................................................................................
No pain
Slight
Mild
6 7
Moderate
8
Severe
9 10 Extreme Worst Possible Pain
Comments Date Of Treatment: .....................................................................................................
Type Of Treatment: ..................................................................................................... Please complete your pain diary as accurately as possible, record the date, the pain score and any additional comments you feel may be useful to your consultant such as pain after a particular activity. We have also included some guidance as to what the numbers relate to, circle the number you feel is most appropriate at the time. Your pain diary will be reviewed by your consultant at your clinic appointment so please ensure that you bring it with you. Should you have any concerns with the pain you are experiencing please get in touch with Mr Yates’ secretary.
Mr Edward Yates Consultant Orthopaedic Surgeon Hip & Knee Specialist
www.edwardyates.co.uk
Day 1
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9
10
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Day 2
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10
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Day 3
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Day 4
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Day 5
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Day 6
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Day 7
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Day 8
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Day 9
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Day 10
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Day 11
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Day 12
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Day 13
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Day 14
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Week 3
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1
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10
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Week 4
0
1
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9
10
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Month 2
0
1
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6
7
8
9
10
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Month 3
0
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10
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Month 4
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Month 5
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10
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Month 6
0
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10
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