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Thyroid Disorder Symptom and Treatment Tracking Sheet

Daily monitoring tool for thyroid patients

Endocrinology

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Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date: ___________________ Physician: _______________ Next Appointment: _________

Daily Symptom Tracker

Vital Signs

  • Morning Temperature: ______°F
  • Resting Heart Rate: ______ BPM
  • Weight: ______ lbs

Symptoms (Rate 0-5, 0=None, 5=Severe)

  • Energy Level: ___
  • Fatigue: ___
  • Cold/Heat Sensitivity: ___
  • Hair Loss: ___
  • Skin Changes: ___
  • Mood Changes: ___
  • Sleep Quality: ___
  • Muscle Weakness: ___

Medication Log

Medication Name: ________________ Dose: _________ Time Taken: _______

Laboratory Values

Test Date Result Range
TSH
Free T4
Free T3

Lifestyle Factors

Diet

  • Iodine-rich foods consumed: _________________
  • Goitrogen intake: ________________________

Exercise

  • Type: ________________
  • Duration: ____________
  • Intensity (Low/Moderate/High): ____________

Notes

Side Effects/Concerns: ______________________ Questions for Next Visit: ___________________

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