Phone: (971) 205-3266
Website: johnsonlaw.com
Email: info@johnsonlaw.com
Pain & Symptom Journal
Daily tracking of symptoms, pain levels, and recovery progress
Patient Name: _________________________________ Date of Accident: ___/___/______
Claim Number: _________________________________ Attorney: Johnson Law, P.C.
Instructions:
- Complete daily: Fill out this journal every day, even on "good" days
- Pain scale: Rate pain from 0 (no pain) to 10 (worst pain imaginable)
- Be specific: Describe symptoms in detail (location, type, duration)
- Include activities: Note what you can and cannot do due to your injuries
- Track medications: Record all pain medications and their effectiveness
- Note triggers: Identify activities or conditions that worsen symptoms
Pain Scale Reference
0-1: No pain
2-3: Mild pain
4-5: Moderate pain
6-7: Severe pain
8-9: Very severe pain
10: Worst possible pain
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________
Date: ___/___/______ Day of Week: _____________
Weather: ☐ Sunny ☐ Rainy ☐ Cold ☐ Hot ☐ Other: ___________
Pain Levels (Rate 0-10)
Head/Neck: ___/10
Shoulders: ___/10
Back: ___/10
Arms/Hands: ___/10
Legs/Feet: ___/10
Overall: ___/10
Symptoms Experienced Today
☐ Headache
☐ Dizziness
☐ Nausea
☐ Fatigue
☐ Stiffness
☐ Numbness
☐ Tingling
☐ Muscle spasms
☐ Swelling
☐ Sleep problems
☐ Memory issues
☐ Concentration problems
☐ Mood changes
☐ Anxiety
☐ Depression
Other symptoms: _________________________________________________
Medications Taken Today
| Medication | Dosage | Time Taken | Effectiveness (1-10) |
|---|---|---|---|
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
| _________________ | _______ | _______ | ___/10 |
Activities & Limitations
Activities I was able to do:
_________________________________________________
Activities I could not do due to pain/injury:
_________________________________________________
Activities that increased my pain:
_________________________________________________
Sleep Quality
Hours slept: _____ hours Quality (1-10): ___/10 Pain disrupted sleep: ☐ Yes ☐ No
Additional Notes
_________________________________________________
_________________________________________________
_________________________________________________