A weekly symptom grid with a consistent 0-5 rating scale, injection-day row and space for changes and questions.
Name:
Week beginning:
Medication and dose:
Record symptoms using the same scale each day: 0 = absent, 1 = very mild, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe.
| Side Effect | Mon | Tue | Wed | Thu | Fri | Sat | Sun |
|---|---|---|---|---|---|---|---|
| Injection Day? (mark with star) | |||||||
| Nausea | |||||||
| Vomiting | |||||||
| Diarrhea | |||||||
| Constipation | |||||||
| Headache | |||||||
| Fatigue / Low Energy | |||||||
| Dizziness | |||||||
| Injection Site Reaction | |||||||
| Abdominal Pain / Cramping | |||||||
| Bloating / Gas | |||||||
| Acid Reflux / Heartburn | |||||||
| Other: ______________ | |||||||
| Other: ______________ |
| Date | Medication or food changes | Notes and questions |
|---|---|---|