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Heart Failure Daily Management Tracker

Patient Self-Monitoring Log Sheet

Cardiology

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Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: //___ Physician: ________________ Phone: ________________

Daily Monitoring Log

Vital Signs

Date Weight Blood Pressure Heart Rate Time Taken

Symptoms Checklist (✓ if present)

  • Shortness of breath
  • Swelling in ankles/feet
  • Fatigue level (1-10)
  • Difficulty sleeping flat
  • Chest pain/pressure

Medication Log

Medication Dosage Time Taken Notes

Activity & Diet Tracking

  • Daily fluid intake: ______ oz
  • Salt intake within limit? Yes/No
  • Physical activity (minutes): ______
  • Activity type: ________________

Warning Signs - Call Your Doctor If:

  • Weight gain of 2-3 pounds in 24 hours
  • Increased shortness of breath
  • Severe swelling in legs/ankles
  • Chest pain
  • Dizziness or fainting

Emergency Contact Numbers

Doctor: _________________ Emergency: 911 Clinic: __________________

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