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Symptom Diary
Instructions
Please monitor your body temperature, pulse rate and blood oxygen saturation regularly, and submit the readings here by 10am, 2pm, and 8pm daily.
If you are experiencing symptoms such as shortness of breath, chest pains, palpitations, light headed or difficulties in breathing, please call 911 immediately.
1
Date & Time
Date:
Reading Time:
10 am
2 pm
8 pm
2
Your Basic Info
Name:
Email:
Phone Number
Age:
3-5
6-8
9-13
14-40
41-60
61-80
3
Your Symptoms
Body Temperature:
Oximeter Readings (e.g. 99):
Pulse (heart beats per minute):
How are you feeling today:
Better than before
Same
Worse
How's your breathing:
Better than before
Same
Worse
Do you have the following symptoms:
Cough
Fatigue
Mucus
Diarrhea
Constipation
Shortness of breath
Dizzy
Nauseous
Vomiting
Any medication taken? (write down the type of medication and dose e.g. number of pills):
Submit