Patient name: ______________________________
Week beginning: ____________________________
Clinician: _________________________________
Why use Chronic pain pacing?
Pacing means balancing activity and rest so that you can stay active without repeatedly doing too much and then needing a long recovery period.
The goal is not to avoid activity. The goal is to find a manageable level of activity and gradually build it up over time.
Aim for consistency rather than doing everything on a “good day.”
My Activity Baseline
Choose one activity that you want to work on.
Activity: ___________________________________
Current comfortable amount: _________________
Example: 10 minutes walking / 5 minutes housework / 15 minutes sitting
My starting target: __________________________
How often: __________________________________
How will I increase it?
Daily Activity Diary
| Time | Activity | Planned or Unplanned? | Duration | Pain Before 0–10 | Pain After 0–10 | Energy 0–10 | Recovery Needed |
|---|---|---|---|---|---|---|---|
| Morning | __________ | __________ | _____ | _____ | _____ | _____ | _____ |
| Midday | __________ | __________ | _____ | _____ | _____ | _____ | _____ |
| Afternoon | __________ | __________ | _____ | _____ | _____ | _____ | _____ |
| Evening | __________ | __________ | _____ | _____ | _____ | _____ | _____ |
Today’s overall symptoms
Pain: 0 1 2 3 4 5 6 7 8 9 10
Fatigue: 0 1 2 3 4 5 6 7 8 9 10
Stress/tension: 0 1 2 3 4 5 6 7 8 9 10
Sleep quality: 0 1 2 3 4 5 6 7 8 9 10
Pacing Check
Before activity
☐ Is this activity necessary today?
☐ Have I chosen a realistic amount?
☐ Do I need to break it into smaller tasks?
☐ Have I planned a short recovery period?
During activity
☐ Am I staying within my planned amount?
☐ Am I noticing increased tension or fatigue?
☐ Can I change position or take a short break?
After activity
☐ Did I stop at my planned point?
☐ How did my symptoms respond?
☐ Did I need a prolonged recovery period?
☐ What would I change next time?
Planned vs. Boom-and-Bust
My warning signs that I am doing too much:
☐ Increasing pain
☐ Increasing fatigue
☐ Muscle tension
☐ Reduced concentration
☐ Irritability
☐ Needing to lie down for a long period
☐ Cancelling activities the following day
☐ Other: ______________________________
When I notice these signs, I will:
Breaks & Recovery
Instead of waiting until symptoms become severe, plan short breaks before you need them.
Activity: ______________________________
Work period: __________ minutes
Break: __________ minutes
Activity: ______________________________
Work period: __________ minutes
Break: __________ minutes
During breaks I can:
☐ Change position
☐ Walk gently
☐ Practice slow breathing
☐ Relax my shoulders/jaw
☐ Stretch gently if appropriate
☐ Drink water
☐ Rest without completely stopping all activity
My Week at a Glance
| Day | Main Activity | Planned Amount | Actual Amount | Pain 0–10 | Energy 0–10 | Did I Pace? |
|---|---|---|---|---|---|---|
| Monday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Tuesday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Wednesday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Thursday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Friday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Saturday | __________ | _____ | _____ | _____ | _____ | ☐ |
| Sunday | __________ | _____ | _____ | _____ | _____ | ☐ |
End-of-Week Review
What went well?
Which activities caused the most difficulty?
Did I have any “boom-and-bust” days?
☐ No
☐ Yes
What happened?
What helped me manage my symptoms?
What would I like to improve next week?
My Next Step
Choose one small, realistic change rather than trying to increase everything at once.
Activity I will work on:
My new target:
When I will do it:
How I will pace it:
Review date: _________________________________
Progress is not measured by having no pain. It can also mean doing more of what matters to you while managing your symptoms more effectively.
Clinician Notes
Clinician: _______________________
Follow-up: _______________________