CBT
fo
r C
hro
nic
Pa
in
W
ork
she
et
Use
th
e f
oll
owi
ng
key
to
ra
te
pai
n:
1 =
No
pa
in
at
all
2 =
Sl
igh
t p
ain
3 =
Ma
nag
eab
le
pai
n
4 =
V
ery
pai
nfu
l
5 =
Un
bea
rab
le
pai
n
Nam
e:
Dat
e S
tar
tin
g:
Dat
e F
ini
shi
ng:
Pai
n
Rat
e p
ain
and
id
ent
ify
sym
pto
ms
Eve
nt
Des
cri
be
the
ev
ent
and
fa
cto
rs
Tho
ugh
ts
Des
cri
be
tho
ugh
ts
and
emo
tio
ns
Beh
avi
our
Des
cri
be
wha
t y
ou
did
Rat
ion
al
Cou
nte
r-
sta
tem
ent
Obj
ect
ive
ly
ass
ess
th
e
sit
uat
ion
Mon
day
T
ues
day
Wedne
sda
y
Thu
rsd
ay
Fri
day
Sat
urd
ay
Sun
day