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.
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CODES FOR SYMPTOMS:
F=FeverC=ChillsHA=HeadacheM=Muscle achesJ=Joint painNC=Nasal congestion/ cough
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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
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Date
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Symptoms
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Rating
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Inter-ventions
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Comment
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Phone Numbers
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Nurse:
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_________________________
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Phone:
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_____________
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Physician:
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_________________________
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Phone:
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_____________
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Other:
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_________________________
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Phone:
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_____________
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Comments
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Patient's Signature:
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_________________________
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Date
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_____________
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Nurse's Signature:
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_________________________
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Date:
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_____________
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Source: Shelton BK: Flulike syndrome, in Yarbro CH, Frogge MH, Goodman M (eds): Cancer Symptom Management (ed 3). Boston: Jones and Bartlett, 2003.
Date Last Modified:
2/9/2005