Patient Name _________________________________________
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:
Other:
Comments
Patient's Signature:
Nurse's Signature:
Date: