CBT for Chronic Pain Worksheet
Use the following key to rate pain:
1 = No pain at all
2 = Slight pain
3 = Manageable pain
4 = Very painful
5 = Unbearable pain
Name:
Date Starting:
Date Finishing:
Pain
Rate pain
and identify
symptoms
Event
Describe
the event
and factors
Thoughts
Describe
thoughts
and
emotions
Behaviour
Describe
what you
did
Rational
Counter-
statement
Objectively
assess the
situation
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday