My Pain Crisis Tracker Only – 360° SCD Hub

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KidZONE

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My Pain Crisis Tracker Only

Date of Pain Incident

MM slash DD slash YYYY

Time of Pain Incident

Hours

:

Minutes

AM/PM

What were you doing when this symptom occured?

Sudden Change of temperature

Working at computer

Exercising

Relaxing

Dealing with Stress

Dehydrated

Sleep Deprivation

Other

What other activity triggered this pain?

Weather Tracker: How was the weather when your symptom(s) started?

Hot (91°F or more)

Mild (61°F – 90°F)

Cold (60°F or below )

How was your hydration at time of symptom onset?

Fully Hydrated

Sort of hydrated

Poorly hydrated

What was your mood right before pain?

Excited and happy

Ok…feeling decent

Neutral – not good, not bad

Not so Good

Very tired

Terrible

What is your main pain crisis?

Tired

Cramping

Pain

Headache

Leg Swelling

Bruising

Sharp Pain

Other

What other pain are you experiencing?

What part of the body is the pain?

Full Body Ache

Head

Shoulders

Arms/Hands

Upper Back

Lower Back

Chest

Stomach

Pelvic Region

Legs

Feet

Rate this Pain Crisis (1-Low, 10-High):

Please enter a number from 1 to 10.

Do you want to add your Vital Signs to this Pain Crisis Entry?

Blood Pressure: Systolic

Please enter a number less than or equal to 300.

Blood Pressure: Dialstolic

Please enter a number from 0 to 300.

What is your pulse oximeter reading?

Please enter a number less than or equal to 300.

What is your body temperature?

Please enter a number less than or equal to 300.

What is your pulse/heartbeat for 10 seconds?

Please enter a number from 4 to 25.

Additional Notes

Edit and/or Print your Data Report

[wpdatatable id=10]

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My Pain Crisis Tracker Only

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