Summit Medical Group
Heart Failure Clinic
“Turning Heart Failure into Heart Success”
PATIENT WEIGHT AND SYMPTOM LOG
MONTH_____________
Weigh yourself every morning, wearing the same amount of clothing.
Check off any symptoms you notice.
Call your health care practitioner if you gain 2 lbs or more in one day, or 5 lbs or
more in one week
Keeping the record will help you recognize early signs of trouble. By getting help
early, you may avoid trips to the emergency room or stays in the hospital.
Date
Weight
Short of
Trouble
Cough
Swelling
Poor
Comments
breath
Sleeping
Location
Appetite
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Module 1