Daily Weight And Zone Log Form printable pdf download

Daily Weight And Zone Log Form

Heart Failure Zone Chart

Write your weight and zone on the back of this page every day.

My target weight is ________ pounds.

Every day, I will use this chart to check my weight, swelling, breathing, and

energy level. I will take action if

ONE

of these is in the yellow or red zone.

Green Zone

Yellow Zone

Red Zone

Take action–

You are doing OK

call today.

call NOW!

and in control.

Dr.

Phone

WEIGHT

No change in my

My weight is __________

weight.

pounds or more.

My weight is __________

pounds or less.

SWELLING

I do not have

I have swelling in my:

swelling.

• foot, ankle or shin

• belly, I feel boated

or pants are tighter

• knee or thigh

• hands or face

I do not feel short

I feel short of breath or

I feel short of breath

of breath.

cough while:

or wheeze at rest.

BREATHING

• walking or talking

Breathing is normal.

I feel less alert.

• eating

Sleep is normal.

I need to sleep sitting

• bathing or dressing

up to breathe.

I need to use more

pillows when I sleep.

ENERGY LEVEL

My energy level is

I am too tired to do

I am so tired that I can

normal.

most of my normal

hardly do any of my

activities.

normal activities.

Tear this page out and keep it next to your scale.

Healing Hearts —

Living Well with Heart Failure

Daily Weight And Zone Log Form

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