f your child has recurrent pains, please collect the following information about the pain during three bouts of pain before you make an initial or follow-up appointment. This information may be very helpful in reaching a correct diagnosis.

1. Date:

Time of day:

Place (home, school, etc.):

People present:

2. Describe the Pain

Where on the body?

How long did it last (in minutes)?

How bad (on a scale of 1 to 10 where 1 = mild, 10 = unbearable)?

What did it keep your child from doing?

3. Triggers for Pain

Thoughts (any stresses) before the pain (within 1 hour)?

Feelings (upset or fearful) before the pain (within 1 hour)?

Activities before the pain (within 2 hours):

Food eaten before the pain (within 4 hours):

4. Treatment

What did you do to make it feel better?

5. Your Observation

What do you think was the cause of the pain this time?