This activity diary should be completed for one week prior to attending the back pain management programme. It will be used during the programme to look at how pain can vary according to activities, mood, time of day and pain relief measures.
During the programme you will examine the diary to see the extent that your lifestyle has been affected, it will also be useful as a reference for you while on the programme when learning new skills.
To fill in the diary:
- Fill in the day and the date at the top of the page.
- For each hour you are the awake, write in the main activity you were doing, remember to add if it was carried out in standing or sitting if appropriate.
- Write down any main thoughts you were having, or comment on your general mood at that time.
- Write down your pain level, where 0 is no pain and 10 is the worst pain.
- Document any medication taken, the name and the amount.
- Document any other pain relieving techniques used, for example relaxation, T.E.N.S.
Example of diary entries:
| Time | Activity | Thinking / Mood | Pain | Medication taken | Other relief measures taken |
|---|---|---|---|---|---|
| Time 08:00 – 09:00 | Activity Getting up, washed and dressed etc. | Thinking / Mood I’ve got a lot of things to do today | Pain 5 | Medication taken ________________________ | Other relief measures taken ________________________ |
| Time 09:00 – 10:00 | Activity Cleaning / vacuuming | Thinking / Mood That it takes so long | Pain 7 | Medication taken ________________________ | Other relief measures taken T.E.N.S. machine |
| Time 10:00 – 11:00 | Activity Shopping | Thinking / Mood Stressed about visitors this evening | Pain 8 |
Medication taken
2 co-proxamol |
Other relief measures taken ________________________ |
| Time 11:00 – 12:00 | Activity Sat watching TV | Thinking / Mood Really fed up. Why is pain still so bad? | Pain 7½ | Medication taken ________________________ | Other relief measures taken Rest |
You will need to bring the completed diary along with you to the programme.
Activity diary
Date and day of the week: ___________________________
| Time | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
|---|---|---|---|---|---|
| Time 01:00 – 02:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 02:00 – 03:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 03:00 – 04:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 04:00 – 05:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 05:00 – 06:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 06:00 – 07:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 07:00 – 08:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 08:00 – 09:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 09:00 – 10:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 10:00 – 11:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 11:00 – 12:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 12:00 – 13:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 13:00 – 14:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 14:00 – 15:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 15:00 – 16:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 16:00 – 17:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 17:00 – 18:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 18:00 – 19:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 19:00 – 20:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 20:00 – 21:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 21:00 – 22:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 22:00 – 23:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 23:00 – 24:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
Please include the time you went to bed, your waking time, the number of times you woke during the night and how rested you felt in the morning (0-5: 0 = not rested, 5 = fully rested).
Activity diary
Date and day of the week: ___________________________
| Time | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
|---|---|---|---|---|---|
| Time 01:00 – 02:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 02:00 – 03:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 03:00 – 04:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 04:00 – 05:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 05:00 – 06:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 06:00 – 07:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 07:00 – 08:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 08:00 – 09:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 09:00 – 10:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 10:00 – 11:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 11:00 – 12:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 12:00 – 13:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 13:00 – 14:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 14:00 – 15:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 15:00 – 16:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 16:00 – 17:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 17:00 – 18:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 18:00 – 19:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 19:00 – 20:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 20:00 – 21:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 21:00 – 22:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 22:00 – 23:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 23:00 – 24:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
Please include the time you went to bed, your waking time, the number of times you woke during the night and how rested you felt in the morning (0-5: 0 = not rested, 5 = fully rested).
Activity diary
Date and day of the week: ___________________________
| Time | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
|---|---|---|---|---|---|
| Time 01:00 – 02:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 02:00 – 03:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 03:00 – 04:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 04:00 – 05:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 05:00 – 06:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 06:00 – 07:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 07:00 – 08:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 08:00 – 09:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 09:00 – 10:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 10:00 – 11:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 11:00 – 12:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 12:00 – 13:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 13:00 – 14:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 14:00 – 15:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 15:00 – 16:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 16:00 – 17:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 17:00 – 18:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 18:00 – 19:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 19:00 – 20:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 20:00 – 21:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 21:00 – 22:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 22:00 – 23:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 23:00 – 24:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
Please include the time you went to bed, your waking time, the number of times you woke during the night and how rested you felt in the morning (0-5: 0 = not rested, 5 = fully rested).
Activity diary
Date and day of the week: ___________________________
| Time | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
|---|---|---|---|---|---|
| Time 01:00 – 02:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 02:00 – 03:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 03:00 – 04:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 04:00 – 05:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 05:00 – 06:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 06:00 – 07:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 07:00 – 08:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 08:00 – 09:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 09:00 – 10:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 10:00 – 11:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 11:00 – 12:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 12:00 – 13:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 13:00 – 14:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
| Time 14:00 – 15:00 | Main activity | What I was thinking / my mood | Pain level | Medication taken | Other relief measures taken |
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