Stressors - check one of the available stressors or add your own in the lined space allocated.
Symptoms - check one of the pre-listed symptoms or add to the lined spaces allocated. Options include urinary frequency, painful intercourse, excessive bleeding, severe cramping, fatigue, back/thigh pain, pelvic/bladder pain and more.
Pain location - mark on the image (both front and back are available)
Pain Overall - enter a number ranking, and check one of the pre-listed available or enter your own on the lines available
Medications - check box to indicate 'Usual Daily Medications' and/or 'Usual Daily Supplements'.
List additional medications with reason, time, dose and whether it helped.
Circle the applicable arrow to specify 'More, Normal, Lower' for Cramping, Period Length, Flow Amount, Clotting'
Circle applicable arrow to indicate 'Increased, Same, Decreased' for Pain, Stress, Fatigue, Energy, Activity, Mental Clarity, Activity L
Issue Tracker - when weakness, pain or discomfort comes sporadically during the day you can enter the symptom here along with when it happened/how long it happened, and rate the severity by circling a number.
Activities - select from prelisted options (walking, self-care, socializing, hobbies, employment, house/yard work, childcare, commute) and enter time. Check box to indicate if you were able to exercise.
Notes - insights, comments, questions, additional activities
Meals & Snacks - list and check applicable box to indicate if meal contained salt, red meat, dairy, gluten, sugar, fats
Daily Assessments - notice that pain and fatigue are increased, energy, activity level and general mood are decreased while stress, mental clarity and sleep quality remain the same/consistent.
Details - cramping and clotting are increased, flow amount remains consistent, and period length is blank as unknown at this point.
Issue Tracker - cramps got really bad at 1pm with a severity of 5 and needed painkiller.
Introductory page has space for personal info including emergency contact, allergies, medical alerts and health conditions.
Enter name, address, phone # for physician, specialists, pharmacy as well as insurance information.
Page for current medications / supplements along with reason and refill due date.
Page for CHANGES to medications and supplements with reason for the change, new dose, and date effective.
Upcoming medical appointments - with whom? for what reason, and date
Tests, date performed, and the results.
Chronic Fatigue Syndrome Journal | Interstitial Cystitis Diary | Adenomyosis Diary | Endometriosis Diary | Fibromyalgia Logbook | Menopause Daily Record | |
---|---|---|---|---|---|---|
Size | 6 X 9 inches | 6 X 9 inches | 6 X 9 inches | 6 X 9 inches | 6 X 9 inches | 6 X 9 inches |
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