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Crohn's Disease Symptom and Treatment Tracking Chart

Daily Progress Monitoring Tool for Patients with Crohn's Disease

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date Started: _________________ Physician: _____________ Contact: _____________________

Daily Symptom Tracker

Rate severity from 0 (none) to 5 (severe)

Symptoms

Abdominal Pain: □0 □1 □2 □3 □4 □5
Diarrhea Episodes: ___ times/day
Blood in Stool: □Yes □No
Fatigue Level: □0 □1 □2 □3 □4 □5
Joint Pain: □0 □1 □2 □3 □4 □5
Appetite: □Poor □Fair □Good

Medication Log

Medication	Dosage	Time Taken	Side Effects

Diet Journal

Foods Consumed

Breakfast: ________________
Lunch: ____________________
Dinner: ___________________
Snacks: ___________________

Trigger Foods Noted

Activity Level

□ Minimal □ Light □ Moderate □ Active

Weekly Summary

Stress Level: □Low □Medium □High Overall Well-being: □Poor □Fair □Good □Excellent

Notes for Doctor

Emergency Indicators

Contact your healthcare provider if you experience:

Severe abdominal pain
High fever (>101°F/38.3°C)
Excessive bleeding
Severe dehydration

Next Appointment

Date: _________ Time: _________

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