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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:

_____________