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  • Vulvar Pain Diary: Date of Last Menstrual Period

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    Mihaela N
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    This document provides a pain diary template for tracking vulvar pain symptoms with sections to record the date and time of pain, rate the severity on a scale of 0-10, describe the pain, note the activity when pain began, list any medications taken, record non-drug pain relief techniques used, and rate the pain after 1 hour. Diagrams of the vulvar region and full body are included to mark locations of pain.

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    PainDiary

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    This document provides a pain diary template for tracking vulvar pain symptoms with sections to record the date and time of pain, rate the severity on a scale of 0-10, describe the pain, note the activity when pain began, list any medications taken, record non-drug pain relief techniques used, and rate the pain after 1 hour. Diagrams of the vulvar region and full body are included to mark locations of pain.

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    © All Rights Reserved
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    12 views1 page

    Vulvar Pain Diary: Date of Last Menstrual Period

    Uploaded by

    Mihaela N
    This document provides a pain diary template for tracking vulvar pain symptoms with sections to record the date and time of pain, rate the severity on a scale of 0-10, describe the pain, note the activity when pain began, list any medications taken, record non-drug pain relief techniques used, and rate the pain after 1 hour. Diagrams of the vulvar region and full body are included to mark locations of pain.

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    © All Rights Reserved
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    Vulvar Pain Diary

    Use the following chart and diagrams to track your pain symptoms. You can record information once a day, several times a day,
    or intermittently throughout the week or month.
    Date of last menstrual period ___________
    Date/ Pain Score How would you What were you Name/Amount Medication Non-Drug Pain Other
    Time (0-10) describe your pain? doing when the of Medication Side Pain-Relief Score Notes
    pain began or Taken Effects? Techniques after
    0 = no pain Burning, sharp,
    increased? Used 1 Hour
    10 = worst pain stabbing, etc.?

    Please indicate where your pain is located on the vulvar diagram. If you experience chronic pain in other areas of
    Mark the areas where your pain is most severe with an “X.” your body, please mark them on this diagram.

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