| Name: |
|
| Date | Time: |
|
| Description of Symptoms |
|
| Pain Scale |
0 (none) - 1 (mild) - 2 (moderate) - 3 (severe)
|
| Other Symptoms |
gas | diarrhea | nausea | dizziness | vomiting
|
| How did you feel? |
happy | sad | mad | anxious | tired
|
| Stressors |
work | school | friends | family
|
| Explanation of Stressor: |
|
| Medications Taken: |
|
| Did meds help? |
yes | no | a little | I don't know
|
| What made the symptoms better? |
|
|
|
| Meals - Time |
list foods and beverages at each meal |
| Breakfast - |
|
| Snack - |
|
| Lunch - |
|
| Snack - |
|
| Dinner - |
|
| Other foods/drinks: |
|
|
|
| Sleep Time / Naps: |
|
|
|
| Notes: |
|
|
|
