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Spine Disorders Progress Tracking Chart

Daily Monitoring Tool for Spine-Related Symptoms and Activities

Orthopedics

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: //___ Diagnosis: ________________ Provider: _________________

Daily Symptom Tracker

Rate severity from 0 (none) to 10 (severe)

Pain Levels

Date Neck Upper Back Lower Back Radiating Pain Notes

Functional Activities

Check ✓ if accomplished without significant pain

  • Walking (30+ minutes)
  • Sitting (1+ hour)
  • Standing (30+ minutes)
  • Climbing stairs
  • Lifting objects
  • Personal care activities

Exercise Compliance

Prescribed Exercises

  1. _________________ Reps: ___ Sets: ___
  2. _________________ Reps: ___ Sets: ___
  3. _________________ Reps: ___ Sets: ___

Weekly Progress Notes

Week of: //___

  • Improvements: _______________________
  • Challenges: _________________________
  • Questions for provider: ______________

Red Flags (Alert your provider if any occur)

  • Sudden severe pain increase
  • New numbness or weakness
  • Changes in bladder/bowel function
  • Fever with back pain
  • Unexplained weight loss

Next Appointment: //___ Provider Contact: ______________

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