Hemorrhoid Symptom Tracker Log Form
Use this form to record and monitor your hemorrhoid symptoms, severity, and related experiences over time.
Date of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptom Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Which symptoms are you experiencing today?
*
Pain
Itching
Swelling
Bleeding
Discomfort
Other
Pain Level (if any)
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Duration of Symptoms Today
Please Select
Less than 1 hour
1–3 hours
3–6 hours
6–12 hours
All day
Possible Triggers Today
Spicy food
Constipation
Heavy lifting
Prolonged sitting
Stress
Other
Relief Methods Used
Sitz bath
Over-the-counter cream
Cold compress
Increased fiber
Pain reliever
Other
Stool Consistency Today
Very hard
Hard
Normal
Soft
Very loose
Impact on Daily Activities
No impact
Mildly affected
Moderately affected
Severely affected
Additional Notes
Submit Entry
Should be Empty: