Back to Myofascial Pain
		Daily Pain Record Use this page to track changes in your pain & find out how it is affected by activities & other factors Mark areas of pain or numbness on the drawing. Use stripes or dots to show numbness & use lighter lines for lower levels of pain & heavy lines for savvier pain. Date ____________ Medication ___________________________ ____________________________________ ____________________________________ Overall Pain Level _______ (1-10)
			Notes on Pain ________________________________________________________________________ ____________________________________________________________________________________ Sleep _____________________________________________________________________________________________ __________________________________________________________________________________________________ Diet ______________________________________________________________________________________________ __________________________________________________________________________________________________ Exercise / Stretches_______________________________________________________________________________ __________________________________________________________________________________________________ Note _____________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________