Colorectal Cancer Monitoring and Symptom Tracking Sheet

Patient Information

Name: _________________ Date of Birth: _________________ Medical Record #: _________________ Date Started: _________________

Daily Symptom Tracker

Rate severity: 0 (none) to 4 (severe)

Physical Symptoms

Nutrition & Wellness

• Daily fluid intake (cups): ___________
• Appetite level (Good/Fair/Poor): ___________
• Weight: ___________

Treatment Record

Medications

• Name: _________________ Dosage: _________ Time taken: _________
• Name: _________________ Dosage: _________ Time taken: _________

Side Effect Notes

Describe any new or worsening symptoms:

Emergency Alerts

Contact your healthcare team immediately if you experience:

• Temperature above 100.4°F (38°C)
• Severe abdominal pain
• Unusual bleeding
• Difficulty breathing
• Severe diarrhea or constipation

Healthcare Team Contacts

Oncologist: _________________ Phone: _________________ Nurse Navigator: _________________ Phone: _________________ Emergency Contact: _________________ Phone: _________________

Notes for Next Appointment