Diary of Symptoms
Skip to main content Skip to navigation
Menu
888-544-4636
888-544-4636

Diary of Symptoms

Overview

You can help your doctor diagnose and treat your condition by being prepared to answer questions about your symptoms. Since some symptoms are difficult to describe, it is helpful to write down information about your symptoms as you experience them during your daily activities.

While waiting for your appointment, keep a diary of your symptoms. This form may help.

Describe the symptom for which you are keeping this diary:

Day

1

2

3

4

5

6

7

Time of day the symptom starts



           

Time of day the symptom bothers you the most



           

Does the symptom come and go during the day?



           

Is the symptom affected by any of the following:

  • Activity
  • Rest
  • Stress
  • Recent changes in your eating patterns, such as skipping meals
  • Prescription or over-the-counter medicines (name of medicine and time of day it affects your symptom)
  • Alcohol or caffeinated drinks (number and time)
  • Smoking or the use of other tobacco products
             

What other symptoms do you have:





           

Rate how you felt today:

1 - Great

2 - Okay

3 - Not good

4 - Bad





           

Other information about your symptom:





           

Credits

Current as of: October 24, 2023

Author: Ignite Healthwise, LLC Staff

Clinical Review Board

All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Current as of: October 24, 2023

Author: Ignite Healthwise, LLC Staff

Clinical Review Board

All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.