Daily Neuropathy Symptom and Care Tracking Log

Patient Information

Name: ___________________ Date Started: ___________________

Daily Symptom Rating Scale

0 = None | 1 = Mild | 2 = Moderate | 3 = Severe | 4 = Very Severe

Daily Tracking Chart

Date: //___

Morning Assessment (6AM-12PM)

• Pain Level (0-4): ___
• Numbness (0-4): ___
• Tingling (0-4): ___
• Location of symptoms: □ Feet □ Hands □ Other: ___________

Evening Assessment (6PM-12AM)

• Pain Level (0-4): ___
• Numbness (0-4): ___
• Tingling (0-4): ___
• Location of symptoms: □ Feet □ Hands □ Other: ___________

Daily Care Checklist

□ Medication taken as prescribed □ Foot inspection completed □ Skin care performed □ Exercise/physical activity (minutes): ___

Triggers Noted Today

□ Standing too long □ Cold exposure □ Physical activity □ Other: ___________

Additional Notes

Mood: □ Good □ Fair □ Poor Sleep quality: □ Good □ Fair □ Poor Activity limitations today: _________________

Weekly Summary

Total days with severe symptoms (3-4): ___ Missed medication doses: ___ New symptoms: ___________________

Bring this log to all neurology appointments