Daily Skin Allergy Symptom Tracking Sheet

Patient Information

Name: ___________________ Date Range: //___ to //___

Daily Symptom Log

Symptom Severity Scale

0 - None | 1 - Mild | 2 - Moderate | 3 - Severe

Daily Record

Date: //___

Symptoms (Rate 0-3)

• Itching: ___
• Redness: ___
• Swelling: ___
• Rash: ___
• Dry/Flaky Skin: ___

Location of Symptoms

• Mark affected areas on body diagram: □
• New areas affected? Yes □ No □

Triggers Encountered Today

□ Foods: ________________ □ Medications: ________________ □ Environmental: ________________ □ Skincare Products: ________________ □ Other: ________________

Treatment Used

• Medications taken: ________________
• Topical treatments applied: ________________
• Time of application: ________________

Additional Notes

• Sleep disruption: Yes □ No □
• Activity limitation: Yes □ No □
• Other symptoms: ________________

Weekly Summary

Overall symptom control: □ Well controlled □ Partially controlled □ Poorly controlled

Number of flare-ups this week: ___

Instructions

1. Complete this form daily
2. Bring to all dermatology appointments
3. Take photos of severe reactions
4. Contact your provider if symptoms are severe or worsening

Emergency Contact Information

Dermatologist: ________________ Phone: ________________ Emergency Contact: ________________ Phone: ________________