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Movement Disorders Daily Tracking Chart

Patient Self-Monitoring Tool for Neurological Symptoms

Neurology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _____________________ Date Range: //___ to //___

Daily Symptom Rating Scale

0 = None | 1 = Mild | 2 = Moderate | 3 = Severe

Symptoms to Track

Motor Symptoms

Time → 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM
Tremor
Stiffness
Balance Issues
Freezing Episodes

Non-Motor Symptoms

  • Sleep Quality (Previous Night): □ Poor □ Fair □ Good
  • Fatigue Level: □ Low □ Medium □ High
  • Mood: □ Low □ Stable □ Anxious

Medication Log

Medication Time Taken Dose Notes

Daily Activities

  • Exercise completed: _____ minutes
  • Activities affected by symptoms today: □ Walking □ Eating □ Writing □ Other: _________

Notes

Special events or triggers that affected symptoms:

Instructions

  1. Complete this chart daily
  2. Rate symptoms at regular intervals
  3. Bring to each neurology appointment
  4. Note any medication changes or side effects

© [Year] [Clinic Name] Neurology Department

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