Monitor Your Hepatitis Management Progress
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Name: _________________ Date of Diagnosis: _________________ Type of Hepatitis: □ A □ B □ C □ Other: _________________
| Date | ALT | AST | Viral Load | Notes |
|---|---|---|---|---|
Rate symptoms from 0 (none) to 5 (severe)
| Date | Fatigue | Nausea | Abdominal Pain | Appetite |
|---|---|---|---|---|
□ Exercise (minutes): _______ □ Hours of sleep: _______ □ Alcohol avoided □ Healthy meal choices
| Date | Provider | Purpose | Follow-up |
|---|---|---|---|
Provider: _________________ Phone: _________________ Emergency Contact: _________________ Phone: _________________
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