Date: _______________________

Mark all locations where pain was located throughout the day with *

Mark all locations where stiffness was located throughout the day with O

Mark all locations where numbness was located throughout the day with [

Did you awake refreshed and alert? Yes No

Was your sleep adequate? Yes No If No, was it safe for you to operate a motor vehicle? Yes No

Did you feel fatigued throughout the day? Yes No

Did your eyes, burn, feel dry, or were they sensitive to light or proximity? Yes No

How visible are your "coon" eyes today? Minimal Moderate Severe

Were they also red or bloodshot? Yes No

Did you notice you have more acne than normal? Yes No

Were you able to comprehend all verbal communication today? Yes No

Were you nauseated, have an upset stomach, or bowel problems today? Yes No

Did you have an appetite today, or want food? Yes No

Did you experience vertigo today? Yes No

Did you experience weakness or drop something today? Yes No

Did you experience twitching, shakes, or tremors today? Yes No

Did you feel depressed or (feel like) crying? Yes No

Were you irritable today? Yes No

Did you experience "fibro fog" (mental confusion, inability to concentrate/think) today? Yes No

Were you Anxious or "hyper" today? Yes No

Were you angry or feel violent today? Yes No

Did you stutter or slur your speech today? Yes No

Did you "run into" something or cause pain by hitting something accidentally? Yes No

Were you hot or cold today, even in a normal room temprature? Yes No

Did your temperature fluctuate visibly today? Yes No

Was the Barometer below 30, did it rain, or did the weather otherwise affect you? Yes No

Did you take your recommended dose(s) of related medications? Yes No

On a Scale of 1-10, rate your pain level. ____________

Please list all activities done today: Watch TV Shopping (food) Shopping (other)