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Personal Neuropathy Monitoring Chart

Daily Symptom and Care Progress Tracker

Neurology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: ___________________

Daily Symptom Rating Scale

0 = None | 1 = Mild | 2 = Moderate | 3 = Severe | 4 = Very Severe

Week of: ___________________

Symptoms Mon Tue Wed Thu Fri Sat Sun
Numbness
Tingling
Burning
Pain
Balance Issues

Daily Care Activities

Check (✓) when completed

  • Foot inspection
  • Moisturizing
  • Gentle exercise
  • Medication taken as prescribed

Blood Sugar Readings (if diabetic)

Morning: _______ Evening: _______

Notes

Temperature sensitivity changes: ________________ New symptoms: ________________ Medication side effects: ________________

Weekly Goals

  1. Steps taken: ________________
  2. Pain-free hours: ________________
  3. Sleep quality (1-5): ________________

Healthcare Provider Contact

Next appointment: ________________ Provider name: ________________ Phone: ________________

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