Personal Hormone Imbalance Tracking Chart

A Comprehensive Self-Monitoring Tool for Endocrine Patients

Endocrinology

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Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date Started: ___________ Endocrinologist: ________

Daily Symptom Tracker

Rate severity: 0 (none) to 5 (severe)

Physical Symptoms

Date Fatigue Weight Changes Sleep Issues Temperature Sensitivity Hair Changes

Mood & Cognitive Symptoms

Date Anxiety Depression Brain Fog Irritability Energy Levels

Medication Log

Date Medication Dosage Time Taken Notes

Laboratory Results

Test Date TSH T3 T4 Cortisol Other

Lifestyle Factors

  • Daily water intake: _______ cups
  • Exercise type & duration: _____________
  • Stress level (1-10): ___
  • Hours of sleep: ___

Notes for Next Appointment



Bring this chart to each appointment with your endocrinologist

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