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Carpal Tunnel Syndrome Daily Symptom Tracker

Patient Self-Monitoring Tool

Orthopedics

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: //___

Daily Symptom Rating Scale

0 = No symptoms 1 = Mild 2 = Moderate 3 = Severe

Weekly Tracking Sheet

Week of: //___

Symptoms Mon Tue Wed Thu Fri Sat Sun
Numbness ___ ___ ___ ___ ___ ___ ___
Tingling ___ ___ ___ ___ ___ ___ ___
Pain ___ ___ ___ ___ ___ ___ ___
Weakness ___ ___ ___ ___ ___ ___ ___

Activity Log

Record activities that triggered or worsened symptoms:

  • Time of day symptoms occurred: __________
  • Activities performed: ________________
  • Duration of activities: ______________

Treatment Notes

  • Wrist brace used? □ Yes □ No
  • Ice/heat applied? □ Yes □ No
  • Exercises performed? □ Yes □ No
  • Medications taken: ________________

Additional Notes

Bring this tracking sheet to your next appointment

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