What Are Your Triggers?
Use this diary to track your gout symptoms and associated triggers. Print it out, fill it in, and take it with you to your healthcare provider's office to discuss your situation.
Gout Flare Onset
Fill in date: (mm/dd/yy) ____/____/______
Time began: _________AM or PM (circle one)
When was your last flare? (mm/dd/yy) ____/____/______
Duration
Date ended: (mm/dd/yy) ____/____/______
Time ended: _________AM or PM (circle one)
Medications taken: _______________________
Effectiveness: (1=least; 5=most) 1 2 3 4 5 (circle one)
Nonmedical treatments: _______________________
Effectiveness: (1=least; 5=most) 1 2 3 4 5 (circle one)
Symptoms
Joint(s) affected: _______________________
Pain severity: (1=not severe; 5=most severe) 1 2 3 4 5 (circle one)
Swelling? Yes No (circle one)
Fever? Yes No (circle one)
Redness? Yes No (circle one)
Other symptoms? Yes No (circle one)
Please explain:
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Has your gout affected other joints in the past? Yes No (circle one)
Which joints? _______________________
Possible Triggers
(Check all that apply.)
___Stress or stressful event
___Joint injury
___Alcohol (type of beverage/amount: _______________________________)
___Food (name: _______________________________)
___Infection or another illness
___Surgery
___Crash diet
___Medicine (name: _______________________________)
___Other (if so, please explain)
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If you have any other comments or concerns, list them here:
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