Side Effect Tracking Sheet

Rate each side effect daily from 0 (not present) to 5 (severe). Mark injection days with a star. Bring this sheet to your provider appointments to help guide dosing decisions.

Name:

Week of:

Medication:

Dose:

Severity Scale:

0 = Not present

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: ______________

Weekly Notes

Record any medication changes, dietary changes, or events that may have affected symptoms this week.

When to Contact Your Provider: If any side effect reaches level 4-5 for more than 2 consecutive days, if you experience persistent vomiting, signs of pancreatitis (severe abdominal pain radiating to back), or any allergic reaction (rash, swelling, difficulty breathing), contact your healthcare provider immediately.