Injury Recovery Tracker

Original Injury Date: Today's Report Date: How do you feel today? What is the daily average pain level? (0-10) What makes the pain worse throughout the day? What areas hurt? Affected body parts: Affected areas of life: Missed work? Yes No Income lost (if any): Did you see a doctor/provider today for your injury? Yes No What did they do for you at the doctor visit? Miles driven (if any): Was sleep affected? Yes No How many hours of sleep did you get? Was sex with your partner affected? Yes No When was the last time you could connect with your partner? Is being a parent affected? Yes No When was the last time you have enjoyed time with your kids? What other health care do you wish to receive? Submit

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