JEN WITTMAN CHHC, AADP Your Thyroid Love Coach

SIDE EFFECTS & SYMPTOM TRACKER

Copyright © 2016 Thyroid Loving Care/The Healthy Plate, LLC.

All rights reserved. No part of this publication may be reproduced, scanned, distributed or transmitted in any form, by any means, electronic or mechanical, without permission in writing from the publisher. Any telephone numbers, addresses, prices, offers and web sites listed in this document are accurate at the time of publication, but they are subject to frequent change.

Disclaimer: The content of the following document is based on research conducted by Jen Wittman, Thyroid Loving Care and/or The Healthy Plate, LLC, unless otherwise noted. The information is presented for educational purposes only and is not intended to diagnose or prescribe for any medical or psychological condition, nor to prevent, treat, mitigate or cure such conditions. The information contained herein is not intended to replace a one-on-one relationship with a doctor or qualified healthcare professional. Therefore, this information is not intended as medical advice, but rather a sharing of knowledge and information based on research and experience. Jen Wittman, Thyroid Loving Care and/or The Healthy Plate, LLC encourage you to make your own health care decisions based on your judgment and research in partnership with a qualified healthcare professional.

These statements have not been evaluated by the Food and Drug Administration. The information in this document and is not intended to diagnose, treat, cure or prevent any disease.

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Medications and treatments affect everyone differently. Some medications may cause a bad reac-tion in one person, but another person may not feel any side effects. When your relative starts a new medication or treatment, use this form to keep a record of any new symptoms that occur. You can review the information at each visit with your healthcare professionals. If any symptoms are very troubling, call your doctor as soon as possible.

Print this form and make copies to track your medication use and any side effects or symptoms that may pop up.

Put a rating number in a box for each day that any of these problems occur.

1 Very Mild 2 Mild 3 Moderate 4 Extreme 5 Disabling

Medication Name:_________________________________ Week Beginning:___________________

Symptom

MO

N

TUE

WE

D

THU

FRI

SAT

SU

N

Description

Aches/Pain

Fatigue

Difficulty BreathingNausea/Vomiting

Sweating

Sensitive to Light

Insomnia

Constipation

Diarrhea

1

Symptom

MO

N

TUE

WE

D

THU

FRI

SAT

SU

N

Description

No Appetite

Overeating

Bleeding

Depression/AnxietyHeart

Palpitations

Weight Gain

Cholesterol ChangesSkin/Nail Changes

Chest Pains

Night

Sweats

Other 1:

Other 2:

Other 3:

Other 4:

Other 5:

2