Symptom Tracker Information

Symptom Tracker Information

Keeping track of how you are feeling can help when discussing mental health with your provider. Print this symptom tracker and keep it somewhere convenient. Make sure to complete it at the end of every day and bring it with you to your next health care visit. Use this tool to:

Track your sleep.

Track your energy.

Track your medicine.

Track your mood.

Medication List

Questions for Your Doctor

Symptom tracker.

Month: How many hours did you sleep in a row last night?

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Rate your energy from 1-10, with five being average, 10 being the highest level of energy and one being the lowest level of energy.

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Did you take your medicine today? Y/N

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

How many meals did you eat today?

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Rate your mood from 1-10, with five being average, 10 being the highest and one being the lowest.

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. 11SOW-MPQHF-WY-B2-19-02

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