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(What is a PDF document?)
- Hospital Discharge Checklist(What is a PDF document?)
- Preventing Falls at Home(What is a PDF document?)
- Using Low-Vision Aids at Home(What is a PDF document?)
- Vertigo: Checklist for Personal Considerations(What is a PDF document?)
- Vertigo: Checklist for the Bathroom and Kitchen(What is a PDF document?)
- Vertigo: Checklist for the Home Environment(What is a PDF document?)
- 10 Principles of Recovery(What is a PDF document?)
Diaries, Charts, and Records
- Alcohol Use: Identifying Reasons to Cut Down On or Stop(What is a PDF document?)
- Asthma Diary(What is a PDF document?)
- Blood Pressure: Home Log(What is a PDF document?)
- Childhood Immunization Record(What is a PDF document?)
- Cirrhosis: Sodium Record(What is a PDF document?)
- Comparing Heart-Healthy Diets(What is a PDF document?)
- Diabetes: Tracking My Feelings(What is a PDF document?)
- Diabetes: Tracking My Foods and Blood Sugar Levels(What is a PDF document?)
- Diabetes: Tracking My Portions From Each Food Group(What is a PDF document?)
- Diabetes: Home Blood Sugar Diary(What is a PDF document?)
- Diabetes in Adults: Record of My High Blood Sugar Emergency(What is a PDF document?)
- Diabetes in Adults: Record of My Low Blood Sugar Problems(What is a PDF document?)
- Diabetes in Children: Record of My Child's High Blood Sugar Emergency(What is a PDF document?)
- Diabetes in Children: Record of My Child's Low Blood Sugar Problems(What is a PDF document?)
- Headache Diary(What is a PDF document?)
- Healthy Eating: Tracking My Servings From Each Food Group(What is a PDF document?)
- Heartburn Symptom Record(What is a PDF document?)
- Heart Failure: Track Your Weight, Food, and Sodium(What is a PDF document?)
- Heart Failure: Symptom Record(What is a PDF document?)
- Incontinence: Voiding Log (Bladder Record)(What is a PDF document?)
- Menstrual Diary to Monitor Premenstrual Symptoms(What is a PDF document?)
- Pain Control Diary(What is a PDF document?)
- Pain Diary(What is a PDF document?)
- Physical Activity Log(What is a PDF document?)
- Record of My Medicines and How Well They Work(What is a PDF document?)
- Rosacea Diary(What is a PDF document?)
- Sleep Diary(What is a PDF document?)
- Symptom Diary(What is a PDF document?)
- Women's Fertility: Charting My Basal Body Temperature (Celsius)(What is a PDF document?)
- Women's Fertility: Charting My Basal Body Temperature (Fahrenheit)(What is a PDF document?)
Making the Most of Your Appointments
- Appointment for a New Problem(What is a PDF document?)
- Daily Medicine Schedule(What is a PDF document?)
- Family Medical History Record(What is a PDF document?)
- First Appointment(What is a PDF document?)
- Follow-Up Appointment(What is a PDF document?)
- Master List of Medicines(What is a PDF document?)
- Medical Tests: Questions to Ask the Doctor(What is a PDF document?)
- New Medicines: Questions to Ask the Doctor(What is a PDF document?)
- Other Treatment: Questions to Ask the Doctor(What is a PDF document?)
- Regular Checkup for a Child(What is a PDF document?)
- Regular Checkup for a Lifelong Condition(What is a PDF document?)
- Surgery: Questions to Ask the Doctor(What is a PDF document?)
Managing Diabetes
- Blood Sugar Testing Times Form(What is a PDF document?)
- Food List(What is a PDF document?)
- Home Blood Sugar Diary(What is a PDF document?)
- Menu Planning Form(What is a PDF document?)
- My Child's Meal Plan for Carbohydrate Counting(What is a PDF document?)
- Physical Activity Log(What is a PDF document?)
- Record of My Child's High Blood Sugar Emergency(What is a PDF document?)
- Record of My Child's Low Blood Sugar Problems(What is a PDF document?)
- Record of My High Blood Sugar Emergency(What is a PDF document?)
- Record of My Low Blood Sugar Problems(What is a PDF document?)
- Tracking My Feelings About Diabetes(What is a PDF document?)
- Tracking My Foods and Blood Sugar Levels(What is a PDF document?)
- Tracking My Portions From Each Food Group(What is a PDF document?)
- Using Low-Vision Aids at Home(What is a PDF document?)
Plans
- ADHD: Form for Establishing a Routine(What is a PDF document?)
- ADHD: Sample School Plan(What is a PDF document?)
- ADHD: Treatment Plan Record(What is a PDF document?)
- Alcohol Use: Plan to Stop Drinking(What is a PDF document?)
- Asthma Action Plan(What is a PDF document?)
- Exercise Planning Form(What is a PDF document?)
- Meal Planning: Menu and Grocery List(What is a PDF document?)
- Parenting: Family Rules Form(What is a PDF document?)
- Planning to Be More Active When You Have Chronic Disease(What is a PDF document?)
- Pregnancy: My Birth Plan(What is a PDF document?)
- Setting Goals: Personal Action Plan(What is a PDF document?)
Screenings and Self-Tests
- Assess Your Drug Use(What is a PDF document?)
- Assess Your Substance Use(What is a PDF document?)
- Assess Your Tobacco Use(What is a PDF document?)
- My Reasons to Quit Smoking(What is a PDF document?)
- Post-Traumatic Stress Disorder (PTSD) Assessment(What is a PDF document?)
- Risk Test For Diabetes(What is a PDF document?)
- Self-Test For Anxiety(What is a PDF document?)
- Stress: How Do You Cope?(What is a PDF document?)
Vaccines and Immunizations
- Adenovirus Vaccine(What is a PDF document?)
- Adult Immunization Schedule(What is a PDF document?)
- Anthrax Vaccine(What is a PDF document?)
- Chickenpox (Varicella) Vaccine(What is a PDF document?)
- Childhood Immunization Catch-Up Schedule: Ages 4 Months to 18 Years(What is a PDF document?)
- Childhood Immunization Record(What is a PDF document?)
- Childhood Immunization Schedule: Ages 0 to 6 Years(What is a PDF document?)
- Childhood Immunization Schedule: Ages 7 to 18 Years(What is a PDF document?)
- Diphtheria/Tetanus/Pertussis (DTaP) Vaccine(What is a PDF document?)
- Haemophilus Influenzae Type B (Hib) Vaccine(What is a PDF document?)
- Hepatitis A Vaccine(What is a PDF document?)
- Hepatitis B Vaccine(What is a PDF document?)
- Human Papillomavirus (HPV) – Cervarix Vaccine(What is a PDF document?)
- Human Papillomavirus (HPV) – Gardasil Vaccine(What is a PDF document?)
- Inactivated Influenza Vaccine (Flu Shot)(What is a PDF document?)
- Japanese Encephalitis – Ixiaro Vaccine(What is a PDF document?)
- Live, Intranasal Influenza Vaccine (Nasal Spray Flu Vaccine)(What is a PDF document?)
- Measles/Mumps/Rubella (MMR) Vaccine(What is a PDF document?)
- Measles/Mumps/Rubella/Varicella (MMRV) Vaccine(What is a PDF document?)
- Meningococcal Vaccine(What is a PDF document?)
- Pneumococcal Conjugate (PCV) Vaccine(What is a PDF document?)
- Pneumococcal Polysaccharide (PPSV) Vaccine(What is a PDF document?)
- Polio (IPV) Vaccine(What is a PDF document?)
- Rabies Vaccine(What is a PDF document?)
- Rotavirus Vaccine(What is a PDF document?)
- Shingles Vaccine(What is a PDF document?)
- Smallpox Vaccine(What is a PDF document?)
- Tetanus/Diphtheria (Td) and Tetanus/Diphtheria/Pertussis (Tdap) Vaccine(What is a PDF document?)
- Typhoid Vaccine(What is a PDF document?)
- Yellow Fever Vaccine(What is a PDF document?)
Last Revised: August 22, 2011
Author: Healthwise Staff
Medical Review: Kathleen Romito, MD - Family Medicine & Brian D. O'Brien, MD - Internal Medicine
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
To learn more visit Healthwise.org
© 1995-2012 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.