POTS Daily Record: For Dysautonomia, Heart Disease, Mitral Valve Prolapse, Neurocirculatory Asthenia, Anemia, Postural Orthostatic Tachycardia Syndrome

Triggers/Concerns and Symptoms

Triggers - pre-listed options include low sodium, sleeping position, heat, stress, dehydration, alcohol, lack of compression, and more.

Symptom Location - mark on the image (both front and back are available)

Symptoms - select from options including vertigo, fainting, shaking/tremors, blood pressure, irregular heart rate, vision, discolored hands or feet, fatigue, brain fog, gastroparesis and more.

Daily Assessments, Blood Pressure, Activities

Circle applicable arrow to indicate 'Increased, Same, Decreased' for Vertigo, Anxiety, Breathlessness, Palpitations, Weakness, Pain, Stress, Fatigue, Energy, Activity, Mental Clarity, General Mood, Sleep Quality

Activities - select from prelisted options (walking, self-care, socializing, hobbies, employment, house/yard work, childcare, commute) and enter time.

Check box for pacing.

Issue Tracker and Meals/Snacks

Symptomatic Activities - If, during an activity, you feel symptoms, space is allocated to enter time, pulse, blood pressure, O2, and the specific issue that caused sypmtoms at the time - for example an activity or exercise. See example.

Meals & Snacks - list and check applicable box to indicate if meal contained salt, red meat, dairy, gluten, sugar, fats

Notes and Medications

Notes - for additional information, insights, questions, what helped

Medications - check box to indicate just your usual daily medications. There is also a checkbox for usual daily supplements.

If additional medications are taken you can list them, the dose, time and whether it helped.

Example of completed section

Daily Assessments - note that vertigo, fatigue, weakness, chest pain and palpitations are marked as increased. Energy and general mood have decreased while anxiety, stress, breathlessness, activity, mental clarity and sleep quality remain the same/consistent. * Only track the items that are pertinent to you.

Example of completed section

Vitals Tracking - noted pulse, BP and O2 levels multiple times during the day with a note to say what activity or issue was happening at the time.

As example - first thing in the morning when getting up pulse was 130. At 2pm after climbing stairs pulse was 128. At 8pm after taking walk felt dizzy - pulse was up while BP was down.

Personal Information and Healthcare Team

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.

Medications and Changes, Exercise Log

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.

Medical Appointments and Avoidance Log

Tests/Results

For general tests and for blood tests

Left Page

Right Page