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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 doctor each week.

Codes for symptoms:

F=Fever

C=Chills

HA=Headache

M=Muscle aches

 J=Joint pain

NC=Nasal congestion or 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 with no relief gained

Date

Symptoms

Rating

Interventions

Comment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone numbers

Nurse:

_________________________

Phone:

_____________

Doctor:

_________________________

Phone:

_____________

Other:

_________________________

Phone:

_____________

Comments:

 

 

 

 

 

 

 

 

 

 

 

Patient's signature:

_________________________

Date

_____________

Nurse's signature:

_________________________

Date:

_____________

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