Chronic Illness Health Cycle Tracking Log Form
Use this form to log and monitor your chronic illness health cycle, symptoms, and related factors for better self-management and communication with your care team.
Date of Log Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Main Symptoms Experienced
*
Fatigue
Pain
Headache
Nausea
Brain fog
Digestive issues
Joint/muscle stiffness
Dizziness
Other
Severity of Symptoms (1 = mild, 10 = severe)
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Describe Today’s Flare or Episode
Medications or Interventions Used
Prescription medication
Over-the-counter medication
Rest
Hydration
Heat/ice therapy
Other
Possible Triggers Identified
Stress
Diet
Weather changes
Physical activity
Sleep disruption
Other
Impact on Daily Activities
*
No impact
Mild impact
Moderate impact
Severe impact
Hours Slept Last Night
Mood Today
Please Select
Very positive
Positive
Neutral
Negative
Very negative
Additional Notes
Submit Log
Should be Empty: