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Patient Information

Name: _________________ Date Started: _________________

□ Palpitations □ Shortness of breath □ Dizziness □ Chest discomfort □ Fatigue □ Other: _________________

Medication Name	Time Taken	Dose
________________	____________	______
________________	____________	______

□ Minimal activity □ Light activity □ Moderate activity □ Vigorous activity

□ Stress □ Caffeine □ Alcohol □ Poor sleep □ Exercise □ Other: _________________

Episodes this week: _______ Longest episode: _______ Symptoms improved?: Yes □ No □

Next Appointment Date: _________________

Keep this chart updated daily and bring it to all medical appointments