My Journal

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My Journal

Name

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This personal treatment journal is intended to help you to follow the treatment plan your doctor recommends. The journal includes:

My Team • Contact information of your doctors, nurses, emergency services, health

insurance, and pharmacies

My Medications • A handy list of all the medications you take that can be shared with your doctor

and pharmacist

My Health • A simple logbook to write down each time you take your medicine and track

how you’re feeling

My Questions • Important questions to remember to ask your doctor

My Support• People and groups to help you during your treatment

My Inspiration• Write down ideas or compelling quotes that inspire you during treatment

Write in this journal to help keep your treatment plan on trackUsing Your Journal

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My Team To help keep on track with your treatment plan, keep a list of the healthcare professionals you turn to for care and answers to your questions.

If I have questions about my treatment, I should contact:

Name

Telephone number

E-mail address

If I have questions about my prescription, I should contact:

Name

Telephone number

My emergency contact:

Name

Telephone number

Other important members of my team:

Name

Telephone number

E-mail address

Name

Telephone number

E-mail address

Name

Telephone number

E-mail address

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My Medicines

Write down all the prescription medicines you take and show this list to your doctor and pharmacist. Make sure to update this section when you start a new medication.

Medication Dose How to take Start date Notes

Prescription Pill (10 mg) Once a day, with or without food

2/5/16 Doctor said I’m responding to the medication.

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My Vitamins and Supplements

Write down any vitamins, supplements, or over-the-counter medicines you take and show this list to your doctor and pharmacist.

Vitamin/supplement How to take Start date Notes

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My Allergies

Write down everything you are allergic to. This can include medicines, foods, beauty products, fabrics, dust, and more. Show this list to your doctor and pharmacist.

What I’m allergic to What to do Notes

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My Health

Use this journal to keep a record of your health, specifically noting when you take your medicine and how you feel on treatment. Then, bring this with you to your next doctor appointment.

If you’re not feeling well, your doctor may be able to prescribe other medicines to make it easier for you to stay on your treatment.

Always take your medicine exactly as your doctor tells you to. To help your doctor know if you are improving or feeling worse, rank how you feel from 1 to 5. A ranking of 1 would mean you feel nothing wrong, while 2-5 would mean you’re feeling progressively worse as the numbers increase.

Check the boxes each day, after you take your medicine as prescribed by your doctor.

Example:

Date Morning dose Evening dose

Rank how you feel

Side effects Tired

Things to tell nurse/

doctor: Feeling low energy today

Notes:

6/1 X1 2 3 4 5X 1 2 3 4 5

9

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

10

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5 1 2 3 4 5

My Health

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

25

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

1 2 3 4 5

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

Date Morning dose Evening dose

Rank how you feel

Side effects

Things to tell nurse/

doctor:

Notes:

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1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

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My Questions

In addition to telling your doctor about any side effects you may experience, you may also have questions about your treatment. Show your doctor these questions at your next office visit, and write down the answers.

Date Doctor Questions Answers

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My Support

Everyone needs support. Learn how to ask for help when you need it. It’s important.Support takes many forms. It can be emotional support. It can be someone to drive you to the doctor. It can be someone to help you get groceries. Write down the friends or social networks you can turn to when you need a little extra help.

You are not alone—connect with others who understand:www.cancercare.orgProvides telephone, online, and face-to-face counseling, support groups, education, publications, and financial assistancewww.caringbridge.orgConnect with your supporters and other patients who want to share their personal storieswww.clearityfoundation.orgHelps eligible women obtain and understand the molecular profile of their tumorwww.facingourrisk.orgEducation, advocacy, and research specific to hereditary breast and ovarian cancerwww.inspire.comJoin a community to share and learn about ovarian cancer, treatment, and supportwww.ocrf.orgA support network that connects survivors, women at risk, and caregiverswww.ovarian.orgLearn how you can support cancer organizations, get medical information, and find future events

Name Phone number E-mail Notes

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My Inspiration

Write down compelling quotes and ideas that inspire you during your journey. You may even want to share with family and friends.

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Copyright © 2016 by Clovis Oncology, all rights reserved. PP-RUCA-US-0192 12/2016