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Ulcerative Colitis Symptom Tracking Chart

Daily Progress Monitoring for Better Disease Management

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date Range: //___ to //___

Daily Symptoms Score (Rate 0-3)

Stool Frequency

Date Number of Stools Blood Present (Y/N) Urgency (0-3)

Pain and Discomfort

  • Abdominal Pain: □ None (0) □ Mild (1) □ Moderate (2) □ Severe (3)
  • Joint Pain: □ None (0) □ Mild (1) □ Moderate (2) □ Severe (3)

General Wellness

  • Energy Level: □ Normal (0) □ Slightly Low (1) □ Low (2) □ Very Low (3)
  • Appetite: □ Normal (0) □ Slightly Reduced (1) □ Poor (2) □ No Appetite (3)

Medication Adherence

Medication Name Dose Time Taken Missed Doses

Diet Log

  • Foods that triggered symptoms: ________________________
  • Foods well-tolerated: ________________________________

Notes for Healthcare Provider

Stress levels: □ Low □ Moderate □ High Other symptoms or concerns: _____________________________

Emergency Warning Signs

  • Severe abdominal pain
  • High fever (>101.5°F)
  • Severe bleeding
  • Severe dehydration

Bring this chart to your next appointment Next appointment date: //___

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