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Headache and nasal symptom note card
Date ____________________ Start time or best estimate ____________________
Start and end
What appeared first, and when did the different symptoms settle?
Where and how
Side, location and your own description of the feeling.
Nose and smell
Blockage, drainage, watery eyes, smell change or a check that was clear.
What came with it
Light or sound sensitivity, nausea, a recent cold or another observation.
Impact and action
What it interrupted, what you used as part of your usual plan, and when.
Question for my clinician
Write the question you want to ask first.
Personal observations only. Not clinically reviewed. These sheets do not diagnose symptoms or replace your care team’s instructions. Do not delay care to complete a diary.
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