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Heart Failure Daily Management Tracker

Patient Self-Monitoring Progress Chart

Cardiology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: ___________________

Daily Monitoring Chart

Vital Signs

Date Weight Blood Pressure Heart Rate Swelling (0-3)*

*Swelling Scale:

  • 0 = None
  • 1 = Slight
  • 2 = Moderate
  • 3 = Severe

Symptoms Checklist

  • Shortness of breath
  • Fatigue level (1-10)
  • Sleep quality (Poor/Fair/Good)
  • Activity tolerance

Medication Log

Medication Dosage Morning Evening Notes

Fluid & Salt Intake

  • Daily fluid intake target: _______ mL
  • Actual intake: _______ mL
  • Salt restriction followed? Yes/No

Activity Log

Type of activity: _________________ Duration: _______ minutes Symptoms during activity: _________________

Notes for Healthcare Provider

Emergency Warning Signs

  • Sudden weight gain (>2 lbs in 24 hrs or >5 lbs in a week)
  • Severe shortness of breath
  • Chest pain
  • Fainting

Contact your healthcare provider immediately if you experience any warning signs

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