Multiple Sclerosis Symptom & Activity Tracking Sheet

Patient Information

Name: ___________________ Date: ___________________ Neurologist: ___________________ Phone: ___________________

Daily Symptom Tracker

Rate severity: 0 (none) to 5 (severe)

Morning Assessment (Time: _______)

• Fatigue Level: □0 □1 □2 □3 □4 □5
• Muscle Weakness: □0 □1 □2 □3 □4 □5
• Balance Issues: □0 □1 □2 □3 □4 □5
• Visual Problems: □0 □1 □2 □3 □4 □5
• Numbness/Tingling: □0 □1 □2 □3 □4 □5

Evening Assessment (Time: _______)

• Fatigue Level: □0 □1 □2 □3 □4 □5
• Muscle Weakness: □0 □1 □2 □3 □4 □5
• Balance Issues: □0 □1 □2 □3 □4 □5
• Visual Problems: □0 □1 □2 □3 □4 □5
• Numbness/Tingling: □0 □1 □2 □3 □4 □5

Daily Activities

Physical Activity

• Exercise Duration: _____ minutes
• Type of Exercise: ___________________
• Activity Tolerance: □Good □Fair □Poor

Temperature & Environment

• Today's Temperature: ____°F/°C
• Heat Sensitivity Issues: □Yes □No

Medication Tracking

• All Medications Taken as Prescribed: □Yes □No
• Any New Side Effects: □Yes □No If yes, describe: ___________________

Notes

Stress Level Today: □Low □Medium □High Sleep Quality: □Poor □Fair □Good Additional Comments: _________________

Weekly Summary

Number of Good Days: _____ Number of Challenging Days: _____ New Symptoms: ___________________

Bring this tracking sheet to your next neurologist appointment