Health Tracking Forms and Checklists

Get Started

This page contains printable checklists, diaries, charts, plans, and self-tests to help you keep track of your health. Use the sleep diary to find out more about what affects your sleep patterns. Print off a form that can help you monitor your blood sugar. Take a quiz to get a better idea of how well you cope with stress. Or print the menu plan and grocery list and post it on your refrigerator to help you make better food choices.

To get started tracking your health, click on a form below.

Checklists

• Evaluating Hospice Programs 
• Preventing Falls at Home 
• Vertigo: Checklist for the Home 

Diaries, Charts, and Records

• Alcohol Use: Identifying Reasons to Cut Down On or Stop 
• Asthma Diary 
• Blood Pressure: Home Log 
• Childhood Immunization Record 
• Cirrhosis: Sodium Record 
• Diabetes: Tracking My Feelings 
• Diabetes: Home Blood Sugar Diary 
• Diabetes in Adults: Record of My High Blood Sugar Emergency 
• Diabetes in Adults: Record of My Low Blood Sugar Problems 
• Diabetes in Children: Record of My Child's High or Low Blood Sugar Problems 
• Headache Diary 
• Healthy Eating: Tracking My Servings From Each Food Group 
• Heartburn Symptom Record 
• Heart Failure: Track Your Weight, Food, and Sodium 
• Heart Failure: Symptom Record 
• Incontinence: Voiding Log (Bladder Record) 
• Menstrual Diary to Monitor Premenstrual Symptoms 
• Pain Diary 
• Physical Activity Log 
• Record of My Medicines and How Well They Work 
• Sleep Journal 
• Symptom Diary 
• Women's Fertility: Charting My Basal Body Temperature (Fahrenheit) 

Making the Most of Your Appointments

• Appointment for a New Problem 
• Daily Medicine Schedule 
• Family Medical History Record 
• First Appointment 
• Follow-Up Appointment 
• Master List of Medicines 
• Medical Tests: Questions to Ask the Doctor 
• New Medicines: Questions to Ask the Doctor 
• Other Treatment: Questions to Ask the Doctor 
• Regular Checkup for a Child 
• Regular Checkup for a Lifelong Condition 
• Surgery: Questions to Ask the Doctor 

Managing Diabetes

• Blood Sugar Testing Times Form 
• Home Blood Sugar Diary 
• Form for Carbohydrate Counting 
• Physical Activity Log 
• Record of My Child's High or Low Blood Sugar Problems 
• Record of My High Blood Sugar Emergency 
• Record of My Low Blood Sugar Problems 
• Tracking My Feelings About Diabetes 
• Using Low-Vision Aids at Home 

Plans

• ADHD: Form for Establishing a Routine 
• ADHD: Sample School Plan 
• ADHD: Treatment Plan Record 
• Alcohol Use: Plan to Stop Drinking 
• Asthma Action Plan 
• Exercise Planning Form 
• Meal Planning: Menu and Grocery List 
• Parenting: Family Rules Form 
• Planning to Be More Active When You Have Chronic Disease 
• Pregnancy: My Birth Plan 
• Setting Goals: Personal Action Plan 

Screenings and Self-Tests

• Assess Your Substance Use 
• Assess Your Tobacco Use 
• My Reasons to Quit Smoking 
• Self-Test For Anxiety 
• Stress: How Do You Cope? 

Immunization Schedules

• Childhood Immunization Record