Clinical Reference Systems: Pediatric Advisor 10.0
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For a pain diary chart, click here

If your child has recurrent pains, please collect the following information about the pain during three bouts of pain before you make an initial or follow-up appointment. This information may be very helpful in reaching a correct diagnosis.

1. Date:

Time of day:

Place (home, school, etc):

People present:

2. Describe the Pain

Where on the body?

How long did it last (in minutes)?

How bad (on a scale of 1 to 10 where 1 = mild, 10 = unbearable)?

What did it keep your child from doing?

3. Triggers for Pain

Thoughts (any stresses) before the pain (within 1 hour)?

Feelings (upset or fearful) before the pain (within 1 hour)?

Activities before the pain (within 2 hours):

Food eaten before the pain (within 4 hours):

4. Treatment

What did you do to make it feel better?

5. Your Observation

What do you think was the cause of the pain this time?