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Shoulder Pain and Movement Tracking Journal

Daily Documentation for Better Treatment Outcomes

Orthopedics

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: //___

Daily Pain Scale

Rate your pain from 0 (no pain) to 10 (worst pain)

Time Pain Level (0-10) Activity at Time of Pain
Morning ___ ___________________
Afternoon ___ ___________________
Evening ___ ___________________

Movement Assessment

Check which movements cause pain:

  • Reaching overhead
  • Reaching behind back
  • Lifting objects
  • Pushing/pulling
  • During sleep
  • At rest

Pain Characteristics

Mark all that apply:

  • Sharp
  • Dull
  • Throbbing
  • Burning
  • Radiating

Daily Activities Impact

Rate difficulty (0=None, 5=Unable):

  • Dressing: ___/5
  • Bathing: ___/5
  • Sleeping: ___/5
  • Work tasks: ___/5
  • Recreation: ___/5

Treatment Notes

Medications taken: ____________________ Ice/heat used: ______________________ Exercises done: _____________________

Additional Observations

Bring this completed form to your next appointment

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