Symptom Record Log

Patient Name _________________________________________

Instructions

Use this chart daily to record the symptoms that you are experiencing. Rate the symptoms according to severity using a scale of 1 to 4 (see below). Under "Interventions,'' record what you did for relief, and under "Comments,'' whether or not it helped. Share this log with your nurse or physician each week.

CODES FOR SYMPTOMS:

F=Fever C=Chills HA=Headache M=Muscle aches J=Joint pain NC=Nasal congestion/cough

SEVERITY RATING FOR SYMPTOMS

1=Able to carry on daily activities normally

2=Symptoms mildly affect my day

3=Severe symptoms but gained relief after intervention

4=Severe symptoms; no relief gained

Date

Symptoms

Rating

Interventions

Comment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Numbers

Nurse:

_________________________

Phone:

_____________

Physician:

_________________________

Phone:

_____________

Other:

_________________________

Phone:

_____________

Comments

 

 

 

 

 

 

 

 

 

 

 

Patient's Signature:

_________________________

Date

_____________

Nurse's Signature:

_________________________

Date:

_____________


STAY CONNECTED

Copyright 2014 Main Line Health

Printed from: www.mainlinehealth.org/stw/Page.asp?PageID=STW016428

The information provided in this Web site is for informational purposes only. It is not a substitute for medical advice. All medical information presented should be discussed with your healthcare professional. See additional Terms of Use at www.mainlinehealth.org/terms. For more information, call 1.866.CALL.MLH.