ASEQ-EHAQ

L'Association pour la santé environnementale du Québec / Environmental Health Association of Québec

Instructions for Activity and Symptom Tracking – MCS

Activity and Symptom Tracking Instructions

Empowering Community and Removal of Barriers (ECRoB) Project

The activity and symptom tracking form is available to print or download at your convenience. This information can help:

  • monitor if you are getting better or worse.
  • function as a data collection tool to show your doctor or healthcare providers.
  • to talk to Human Resources in the workplace.
  • be shared with a lawyer or any professionals.
Date and TimeRecord the specific date and time of each entry. Be as accurate as possible in noting the exact time when the symptoms began or when an exposure occurred. This helps establish a clear timeline for medical and legal reference.
Location/ActivityDescribe the location or activity where the symptom or exposure event took place. Include details about the environment, such as whether it was at home, work, a public place, or during a specific activity (e.g., grocery shopping, attending a social event).
SymptomsList each symptom you experience during the entry, such as headaches, brain fog (lack of cognitive function), respiratory difficulty, skin reactions, etc. Provide a detailed description of the symptom’s characteristics, duration, and how it impacted you. For example, specify if the headache was throbbing or describe the skin reaction.
Severity (1-10)Rate the severity of both the symptom(s) and exposure on a scale from 1 to 10, with 1 being the mildest and 10 the most severe. Use this scale consistently to assess the intensity of your symptoms and the impact of the exposure on your health.
ExposureIdentify any known or suspected sources of exposure that may have triggered the symptoms. This could include fragrances, cleaning products, chemicals, or specific environmental factors. Document the exposure source with as much detail as possible, such as brand names, ingredients, or a description of the substance or condition you were exposed to.
NotesUse the “Notes” section to provide additional information or context that may be relevant to your symptoms or exposure such as barriers encountered or problems that arise. Include any relevant observations, actions taken, or interactions with others that could offer insight into the situation.