LDN Patient Symptom Form

We ask that the symptom sheet is completed on a weekly basis.

1. Start your medication on Sunday.
2. Weekly on Sunday access your symptoms and using the number scale document the degree of severity of symptoms for that day. Scale: 0 (none) -5 (severe).
3. The goal is to document how symptoms respond to therapy over time.

TIP: Fill out the sheet on the same day every week. It is very useful to have the symptoms recorded weekly so your healthcare team can review. The answers provided will allow the pharmacists the details needed to recommend your customized dose to your prescriber. All information provided will be kept confidential.

We appreciate your commitment to better your health and your participation will play a role in your success!