Diary of Symptoms

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: