Multiple Chemical Sensitivity (MCS) Activity and Symptom Tracking
Multiple Chemical Sensitivity (MCS) Activity and Symptom Tracking
Empowering Community and Removal of Barriers (ECRoB) Project
Date:
| day | quality of sleep (1-10) | activities | symptoms | source/s of exposure | level of capacity after exposure (1-10) | problems and barriers encountered (1-10) |
| Sunday | ||||||
| Monday | ||||||
| Tuesday | ||||||
| Wednesday | ||||||
| Thursday | ||||||
| Friday | ||||||
| Saturday |
This form is available to print or download at your convenience. This information can help to: monitor if you are getting better or worse, and you can show this chart to your doctor or health professional, help to talk to Human Resources in the workplace, and share it with a lawyer or any professional.
| quality of sleep | On a scale of 1 to 10, 1 being extremely poor and ten being close to perfect. How did you feel when you woke up in the morning? |
| activities | What did you do that made you ill? Was it the: workplace, bank, grocery store, hospital, doctor’s office, etc? |
| symptoms | Write your symptoms. |
| source/s of exposure | What were you exposed to? |
| Level of capacity after exposure | On a scale of 1 to 10, how do you feel and for how long? Hours? Days? |
| Problems and barriers encountered | If you asked for accommodation, how were you responded to? Enter names, addresses, and times. Did you ask for accommodations before you went to this place? |