TREATING CHRONIC PAIN USING VIRTUAL REALITY EXERCISES
Participant Initials Participant Number
Date Day 2
Pain and treatment diary
Please complete the following table for each day. The record will help monitor the progress of treatment and any patterns of improvement.
To fill in the table, it is important to complete the questions below each time you do the virtual reality exercises (twice per day). This will help us get a better
understanding about your pain across the weeks. When rating your pain use the same scale as below, where zero (0) means no pain, and ten (10) means worst possible pain.
Select one number that best describes your pain for each situation: Moderate Pain
No Pain l l l l l l l l l I I Worst Possible Pain
Pain Dairy 0 1 2 3 4 5 6 7 8 9 10
Pain/ medication
Week 1 Monday Morning Monday Afternoon Tuesday Morning
MoOVi 1 Tuesday Afternoon Wednesday
Morning
Wednesday
Afternoon Thursday Morning Rate your pain
before virtual exercises Rate your pain
after virtual exercises
TREATING CHRONIC PAIN USING VIRTUAL REALITY EXERCISES
Participant Initials Participant Number
Date Day 2
Pain and treatment diary
Please complete the following table for each day. The record will help monitor the progress of treatment and any patterns of improvement.
To fill in the table, it is important to complete the questions below each time you do the virtual reality exercises (twice per day). This will help us get a better
understanding about your pain across the weeks. When rating your pain use the same scale as below, where zero (0) means no pain, and ten (10) means worst possible pain.
Select one number that best describes your pain for each situation: Moderate Pain
No Pain l l l l l l l l l I I Worst Possible Pain
Pain Dairy 0 1 2 3 4 5 6 7 8 9 10
Pain/ medication
Week 1 Monday Morning Monday Afternoon Tuesday Morning
MoOVi 1 Tuesday Afternoon Wednesday
Morning
Wednesday
Afternoon Thursday Morning Rate your pain
before virtual exercises Rate your pain
after virtual exercises