Leukemia Daily Monitoring and Symptom Tracking Sheet

Patient Information

Name: _________________ Date: _________________ Medical Record #: _________________

Daily Vital Signs

• Temperature: Morning ____ °F Evening ____ °F
• Blood Pressure: Morning / Evening /
• Heart Rate: Morning ____ Evening ____

Symptom Tracking

Rate severity (0-10, 0=none, 10=severe)

Physical Symptoms

• Fatigue: ____
• Bruising/Bleeding: ____
• Bone/Joint Pain: ____
• Night Sweats: ____
• Shortness of Breath: ____
• Appetite Loss: ____

Blood Count Values (if tested)

• White Blood Cells: ____
• Red Blood Cells: ____
• Platelets: ____
• Hemoglobin: ____

Medication Log

| Medication | Dose | Time Taken | Side Effects | |------------|------|------------|--------------|| | | | | | | | | | |

Important Notes

• Record any infections or illnesses: _________________
• Document any emergency room visits: _________________
• List questions for next appointment: _________________

Emergency Contact Information

Oncologist: _________________ Phone: _________________ Emergency Contact: _________________

Seek immediate medical attention if you experience:

• Fever above 100.4°F (38°C)
• Uncontrolled bleeding
• Severe shortness of breath
• Chest pain
• Confusion or dizziness