Gallbladder Disease Symptom and Diet Tracking Sheet

Patient Information

Name: _________________ Date: _________________

Symptom Tracker

Pain Assessment (Rate 0-10)

• Upper right abdomen: ___
• Between shoulder blades: ___
• Right shoulder: ___
• Time pain started: ___
• Duration: ___ hours

Associated Symptoms (Check all that apply)

□ Nausea □ Vomiting □ Bloating □ Fever □ Chills □ Jaundice

Dietary Log

Meals Today

Breakfast: ___________________ Time: _____ Lunch: ______________________ Time: _____ Dinner: _____________________ Time: _____ Snacks: _____________________ Time: _____

Fat Content Assessment

□ Low-fat meals □ Moderate-fat meals □ High-fat meals

Trigger Tracking

Symptoms occurred after: □ Eating □ Specific food: _______________ □ Physical activity □ Other: _____________________

Medications

Taken today:

Notes

Emergency Warning Signs

• Severe abdominal pain lasting >5 hours
• Fever >101°F
• Inability to keep food down for >24 hours
• Jaundice (yellowing of skin/eyes)

Contact your healthcare provider if you experience any warning signs