Download and print as a PDF (216kB pdf)
Please note: this diary is designed to be printed and filled in manually. You can also print the PDF copy available here.
Patient details:
Diagnostic injection:
Date: Time:
What should I do with this diary?
After your injection, please complete the pain diary here. Have it to hand for your follow-up telephone appointment.
What will the diagnostic injections do?
The aim of these injections is not to provide long-term pain relief. They are to help us diagnose where your pain is coming from. You may feel your pain gets better afterwards, but this is likely to be temporary (although sometimes it may be long lasting).
What happens after I have these injections?
At an arranged time after this procedure, you will have a telephone appointment with one of the doctors or nursing staff. During this appointment, we will ask you for the information you have recorded in this diary.
This information is important to help assess your response, so please keep this diary safe.
Please complete the table below to record your pain scores for 24 hours after your diagnostic injection:
Please rate your pain using the below rating scale.
| Time | Pain score |
|---|---|
| Before the procedure |  |
| After the procedure | |
| 1 hour | |
| 2 hours | |
| 3 hours | |
| 4 hours | |
| 5 hours | |
| 6 hours | |
| 12 hours | |
| 24 hours | |
| Date and time pain returned to pre-injection levels |
This leaflet is intended for patients receiving care in Southlands.
The information in this leaflet is for guidance purposes only and is in no way intended to replace professional clinical advice by a qualified practitioner.
Today’s research is tomorrow’s treatments. That’s why UHSx is proud to be a research-active Trust. Find out how you can get involved.
Visit our website www.uhsussex.nhs.uk/research-and-innovation/information-for-patients-and-public or scan the QR code: 