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Pancreatic Disorder Symptom and Treatment Progress Tracker

Patient Self-Monitoring Chart for Pancreatic Conditions

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date Started: _________________ Diagnosis: _____________ Provider: ____________________

Daily Symptom Tracker

Pain Assessment (Scale 1-10)

Date AM PM Location Triggers

Digestive Symptoms

  • Nausea: □ None □ Mild □ Moderate □ Severe
  • Vomiting: Number of episodes ___
  • Stool Changes:
    • Color: □ Normal □ Clay-colored □ Dark
    • Consistency: □ Normal □ Loose □ Hard

Dietary Monitoring

Food Diary

Time Foods Consumed Reaction

Fat Intake Tracking

  • Daily fat intake goal: ___ grams
  • Actual intake: ___ grams

Medication Log

Medication Dose Time Taken Side Effects

Weekly Measurements

  • Weight: ___ lbs
  • Blood Sugar (if applicable): ___ mg/dL

Notes for Healthcare Provider

Next Appointment

Date: _____________ Time: _____________

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