PAIN DIARY
STEP 3

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​​COMPLETE YOUR DAILY PAIN DIARY


Complete this form only after you have received your UNIQUE PATIENT ID number AND completed the Patient Profile Registration form.

You can complete your Daily Pain Diary as often as you like and you can limit your responses below to include as much or as little information as you would like to share​.

By using this Pain Diary, you undertsand that this does NOT form part of any medical treatment you may be undergoing or considering and is used at your own discretion.

As a medical device manufacturer, Algotec Research and Development takes patient confidentiality very seriously, so it is important that you ​​​ONLY USE THIS ALGOTEC PAIN DIARY IF: [1] you consent to the information you provide below being shared with your Pain Doctor, and [2] you consent to the information you provide below being used by Algotec in evaluating the safety and performance of the product, and to aid future research and development. 
Your UNIQUE PATIENT ID number
I consent to this information being shared with my Pain Doctor. Indicate YES or NO
I consent to Algotec using this information for research purposes. Indicate YES or NO
Is there anything else you would like to tell us about your pain?
With 0 being no pain and 10 being your worst pain, what is your pain today?
Were there any particular activities or events which aggravated your pain today?
Have your pain medications Increased, decreased or are they unchanged when compared to pre PENS?
What was the date of your last PENS therapy treatment ?
Would you have PENS therapy again if required ?
How would you describe your general sense of well-being today?
Where exactly do you feel this pain today?
What pain medication, if any, have you taken today?
How active have you been today - more, less or unchanged ?
Where do you normally feel the pain ?
Send
​​​​The Algotec R&D PENS therapy Daily Pain Diary is available through our website or through the Algotec PENS App which can be download from Google Play and the iStore​

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