Heart Function Log Sheet
ADVERTISEMENT
1
2HEART FUNCTION CLINIC
(250-519-1601)
HEART FUNCTION LOG SHEET
Name _____________________________________________
cups/ounces/mls 1 cup = 8 oz = 250 ml
Fluid Restriction __________________
Goal/Dry Weight ________________________________________
Date
Daily Weight
Daily Fluid Intake Total
Activity/Exercise
Symptoms/
(before breakfast)
(in time or distance)
Medication Chances
Monday
Tuesday
Wednesday
Thursday
,
Friday
Saturday
Sunday
Date
Daily Weight
Daily Fluid Intake Total
Activity/Exercise
Symptoms/
(before breakfast)
(in time or distance)
Medication Changes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Note the following signs & symptoms that may mean worsening heart failure or fluid retention: SHORTNESS OF BREATH, WEIGHT GAIN OR LOSS,
FATIGUE, SHORTNESS OF BREATH WHILE LYING DOWN AT NIGHT, ANKLE SWELUNG, or ABDOMINAL SWELLNG OR BLOATING.
If you gain 2 Ib/ day x 2 days or 5 Ib in a week, please call your physician or the Heart Function Clinic…/
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical