Patient Self-Monitoring Progress Record
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Name: _________________________ Date of Birth: _________________ Medical Record #: ______________
| Time | Fluid Intake (mL) | Urine Output (mL) | Notes |
|---|---|---|---|
| 6 AM | |||
| 9 AM | |||
| Noon | |||
| 3 PM | |||
| 6 PM | |||
| 9 PM | |||
| Total |
Medication Name: ________________ Dosage: ________________________ Time Taken: ____________________
Blood Pressure: ________________ Weight: ________________________ Other Symptoms: ________________
Total Daily Fluid Intake Range: ______________ Average Daily Urine Output: ________________ Symptom Changes: _________________________
Please bring this chart to your next endocrinologist appointment
For Medical Use: Reviewed by: _______________ Date: _____________________ Next Appointment: __________
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