Arthritis Pain Medication Use Log Form
Log your arthritis pain medication use and monitor your pain management over time.
Date of Medication Use
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Medication Use
*
Hour Minutes
AM
PM
AM/PM Option
Medication Name
*
Dosage (e.g., 500 mg)
*
Pain Level Before Medication (0 = no pain, 10 = worst pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Pain Level After Medication (0 = no pain, 10 = worst pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Did you experience any side effects?
*
No
Yes
If yes, please specify the side effects
Additional Comments
Submit Log
Should be Empty: