In the spaces provided below, please record your daily weight, blood pressure, temperature, and 24-hour intake and output (in css) and the time you took these readings. In the medication section, fill in your prescribed dose and scheduled times, and check the appropriate spaces after you've taken your medications.
Name:___________________________________
Date:____________________________________
|
9 a.m |
1 p.m. |
5 p.m. |
9 p.m. |
| Medication |
|
|
|
|
| Cellcept (1 pill = 250 mg) |
1000 mg |
|
1000 mg |
|
| Prednisone (follow taper) |
|
|
|
|
| Diflucan |
100mg |
|
|
|
| Septra |
1 Tablet |
|
|
|
| Colace |
100 mg |
100 mg |
100 mg |
|
| Pepcid |
|
|
|
20 mg |
| Niferex Forte (May start at home) |
150 mg |
150 mg |
150 mg |
|
| Baby Aspirin (May start at home) |
1 Tablet (81 mg) |
|
|
|
|
9 a.m |
1 p.m. |
5 p.m. |
9 p.m. |
|
| Weight |
|
|
|
|
|
| Blood Pressure |
|
|
|
|
|
| Temperature |
|
|
|
|
|
| 24-hour intake |
|
|
|
|
|
| 24-hour output |
|
|
|
|
|
For More Information
If you have any questions or concerns, please call us at 216.444.6996. We will be happy to answer your questions.