Symptom diary template
A one-page, two-week template you can print today (print two for a month). Write your own symptoms in the first row of columns, score each one from 0 to 10 every day, and add a line of notes when the day was different. Bring it to your appointment with your questions at the top.
Download
Tips for keeping it going
- Fill it in at the same time each day, even if it is only the scores.
- Zeros count. A good day is part of the record.
- Keep notes to one line, and only when something was different.
Rather not print?
Brookday keeps the same diary on your phone, and turns a month of it into a report for your doctor. It records what you enter and does not interpret it.
Price: Logging, history, charts and exporting your own data are always free, for as many days as you like. Your first doctor PDF costs nothing, and more doctor PDFs need a one-time unlock for $14.99. It doesn't renew.
Printable symptom diary (two weeks)
Brookday · Free printable · Large print
| Date | Symptom 1 (0–10) | Symptom 2 (0–10) | Symptom 3 (0–10) | Sleep (h) | Energy 0–10 | Pain 0–10 | Notes |
|---|---|---|---|---|---|---|---|
Printable symptom diary (two weeks): filled-in example
Filled in: an example
Fictional people and entries, to show the level of detail that helps.
| Date | Symptom 1 (0–10) | Symptom 2 (0–10) | Symptom 3 (0–10) | Sleep (h) | Energy 0–10 | Pain 0–10 | Notes |
|---|---|---|---|---|---|---|---|
| Mon 7 Sep | 6 | 3 | 2 | 6.5 | 4 | 5 | Long drive, skipped lunch |
| Tue 8 Sep | 2 | 1 | 0 | 8 | 7 | 2 | Walked at lunch |
| Wed 9 Sep | 4 | 2 | 1 | 7 | 6 | 3 | — |
Brookday records what you enter and reports it back. It does not diagnose, interpret, suggest treatment or calculate anything about medication. It is a notebook, not a clinician.