Excel symptomdiary userguide
Version 2007/E1

Patients suffering from chronic illness(es) have my permission to download
the MASTER Excel symptom diary and userguide from http://LymeRICK.net - and may modify, save and use their own personalized version and may use this tool for FREE - in order to help create better overview and keep track of course of a very complex long term disease symptomatology.

The diary was c
reated and is copyright by Marie Kroun, MD - Denmark. Email: kroun@ulmar.dk
My name, copyright notice and email address must NOT be removed from the diary and the MASTER TEMPLATE may not be altered in any way by others than myself, and may not be distributed via other websites / media than http://LymeRICK.net - this of course to ensure that there is ONLY ONE VERSION - the latest update - of the diary available on the Internet. Don't try to correct the calculations or the curve drawings yourself, because this could lead to unexpected errors; you should always report found errors and suggest improvements to me personally - I'll then correct and update the MASTER DIARY on the LymeRICK website ASAP.

The symptomdiary was developed in a danish Microsoft Excel version 2003 with help from project participant, that were all highly suspect of / or proven (positive antigen test) to be suffering from tickborne infection(s), mainly borreliosis; but the diary would be useful to help evaluate and follow up on the course of any chronic illness. The danish version has been in use for 5 years and no errors have been found in the last year before translation into English. However, I do not guarantee it will work on your computer, i.e. when the diary used in other language versions of Excel? - in DK we use COMMA (,) as decimal delimiter, and date form is DD-MM-YYYY (short DD-MM-YY), if you use other formats, it might create problems? -  I have not been able to test the translated version of the danish diary in english versions of Excel - please try it and report back to me how it works, especially if you experience any errors. Suggestions for improvement are very wellcome, likewise should you find any errors, or if you need help with evaluation of your personal diary, feel free to contact me.
BUT NEVER SEND YOUR DIARY TO ME AS EMAIL ATTACHMENT; always write me an email first and present yourself, then I'll give you a personal upload area on my webserver to upload the diary!

Make sure you have downloaded and use the latest version of the diary from LymeRICK, otherwise I will not spend time to help find and correct eventual errors reported!

The idea of using a symptomdiary is far from new in medicine, but most doctors just ask their headache patient to make notes on headache attacks only and asthma patients to do peak flow metry in order to follow course, but with this diary you can follow ANY SET OF SYMPTOMS and analyze them.
Using a score system is not new either. Many have used a VISUAL ANALOG SCALE - usually grading symptoms from 0-10 - in order to try to MAKE SYMPTOMS MEASURABLE AND COMPARABLE OVER TIME - both in the individual patient during course of his/her illness, and/or when comparing different patients, when the doctor pool data from several patients and find common features of a particular "disease pattern".

However, without putting EXPLANATIONS IN WORDS to what a particular SYMPTOM SCORE means exactly, we risk that psychological factors may influence the score much, depending on the patients mood that day i.e. "same symptom grade" may be scored more variable over time and the perception of a particular score number may differ quite much from patient to patient and among patients and doctors, depending on what they have had of previous experiences, grade of tolerance to pain etc. etc.
No patient - that spontaneously chose to use the 10 point visual analog score system in the beginning - could ever tell me in clear words when they gave 7 respectively 8 points - therefore I could not be sure they would use the score consistent over time for same grade of a certain symptom.
After letting project patients chose and test different score systems and gaining experience from that -  I decided to steamline and use a simpler scale with fewer numbers, the severity of each integer grade values were explained by words, as follows: 
0=  normal; normal function, should NOT be written into the diary; empty cells automatically count as ZERO!
1=  slighly abnormal (reduced function)
2=  moderately abnormal (function difficult)
3=  severely abnormal (worst ever, function impossible)
and >3 can be given IF a patient later should worsen above what (s)he thought possible / have experienced before!
In this simpler visiual analog scale, it becomes possible to explain grades / symptoms in plain words, which we humans can usually relate to much better, than we can to numbers.
OVERALL SEVERITY / function loss can then be calculated by dividing the peak and the basic symptom score level respectively by 3 i.e. number of symptoms scoring highest niveau, where function is impossible!
However it soon turned out that the "sensibility" of the above 0-3 score system was reduced if all symptoms - 1/2 or 3/4 in between two integer scores - are rounded down to nearest integer value all the time; then minor symptom fluctuations may be cut-away from the curves, especially when a patient has few swinging symptoms and many relatively stabile high symptoms, which is quite often the case in long term illness.
Thus  if 0,5 points is removed from say 10 symptoms each, this would give a reduction of total 5 point on the total symptom score, i.e. 10% missing points on the total score if the patient has a high basic total score level about 50 points - which again corresponds to maximum score (= patient is unable to function because of the symptom) for as many as 16 symptoms - this is clearly a very disabling condition - the patient need help!

Both the simplicity of the 0-3 point scale and sensitivity can both be easily achieved, however, by asking the patient to score his/her symptoms in DECIMAL VALUES - illustrated in the ruler below:
Judging the diary:
Because computers / the Excel spreadsheet can calculate / sum up NUMERIC SCORES and draw curves for us - per symptom, per organsystem, and total plus treatment curves  - all made 
automatically and instantaneouly, along as the patient enters the scores ... we can create overview over a complex multi-symptomatology, evaluate for potential symptom triggers, as well as keep a close eye on the course of disease over long period of time, perhaps during a trial treatment, as well as register adverse effect; when the diary has been kept for a while (at least 1 month in chronic illness) before, and later during and a suitable period (at least 3 months) after a trial intervention, the result of this intervention can be easily judged on the curves and analyzed in details: declining scores means improvement, increasing scores means worsening (side effects > beneficial effect) and no change / lag phase, means there was no effect; logically a harmful or ineffective treatment should be stopped, when we've seen it does not help the patient!

Fluctuating symptoms points us to either cyclical infectious acticity or to  repeated exposure at timely intervals to other environmental toxins / allergens that cause "infection like" symptoms.
The cycle may tell which infection(s) could play a role in the disease picture, if typical / known growth pattern from laboratory science or previous clinical experience!
Persistent, non-fluctuating symptoms can be due to either permanent tissue damage, accumulated toxins and/or accumulated degradation products - or probably a combination of the three.

Active infections often produce toxins and degradation products that trigger immune reaction; even after active infection - and hence further microbial toxin production - has been gunned down by relevant causal treatment (antibiotic), it can happen, that excretion of toxins and degradation products (healing) can be very slow and insufficient, possibly because of a bottle-neck situation in the detoxification system - then excess toxins can't be excreted (in between symptom flares), but tend to accumulate over time and may cause gradual worsening, because when not eliminated, continue to trigger all the proinflammatory immune reactions, i.e. will give the patient continuing symptoms on a relatively high basic level after infection (post-infectious symptoms)
Only ACTIVE MICROBES - when sensitive - can be gunned down by antibiotic treatment.

CHRONIC ILLNESS - (neuro-) toxin mediated? - symptoms may not occur until "the cup" has been filled and the detoxification system is being overwhelmed. It is a simple matter of balance between input and output. The more toxic stuff (including microbial toxins) the system have accumulated over time and need to degradate and excrete via the same metabolic pathway, the more likely a bottle-neck situation can occur, when further - microbial - toxins begin to pile up on top, and when the treshold become exceeded, symptoms are produced. When severe, the patient may suffer from multiple chemical sensitivity symptoms (MCS), where just a tiny bit more will results in very severe symptom aggravation.  In these cases it is pertinent that the patient - and only (s)he can do it! - cleans out all unnecessary things and only take in healthy foods; many medicines have to go through the same pathway too and severe adverse effects can be expected in the MCS patient; to reduce worsening reaction start with very low dose, and increase very slow and not until an eventual induced adverse reaction have cleared! 
Excretion of some toxins can be increased by toxin binders; I refer you to read Ritchie Shoemakers books and website for further nformation on this subject: http://www.chronicneurotoxins.com
In borreliosis, we have unfortunately no way to tell the difference between a true cure (eradication of all borrelia from the host's body) or latent stage (dormant, inactive bugs that might later have a chance to grow up again).
Therefore we will need to keep an eye on the basic symptom level for a long time after stopping antibiotic treatment!
According to dr. Burrascano there is a very good chance that a patient that has not had relapsed within 3 years after stopping antibiotic treatment, will not relapse later - i.e. the follow-up time should be at least 3-5 years (like most cancer patients); on the other hand treatment should probably continue for as long as it seem to be of benefit to the patient, i.e. as long as the patient continues to improve and there is still sign of activity flares, judged by falling basic symptom level and repeated peaks, usually at monthly intervals.
In the diary we can evaluate which symptoms swing (together) and which don't - i.e. which symptoms represent flare activity, from which we may guess on a particular infection.
The flare pattern can say us something about which infection(s) could be in play (which should we use money to test for?) because some microbes have a cyclical growth pattern giving the patient a cyclical symptom pattern - just to mention a non-tick vektor borne infection: malaria, this infection is also named "tertiary fever" because the relapses comes at 3-4 days interval ...  borrelia have a "quick" cycle of about 9 days interval (like in relapsing fever borreliosis) and a slow cycle of 3-4 weeks interval, probably dependent on how long time they have been dormant before reverting to activity (Brorson).
Likewise malaria cycle with infectious disease symptoms every 3-4 days, and the ringforms found in RBC of my project participants seem to flare at about 4-5 days intervals ...

The symptom list and grades:

The long symptom list came about, by adding all symptoms project patients registered, some used dr. Burrascano's list (see his guidelines at http://ilads.org ) and I added some symptoms / triggers too, plus MEASURES like temperature and pulse, which are important infectious markers, that must be followed at least a month to judge if there are fluctuations like in "relapsing fever borreliosis" that gave fever (plus general malaise symptoms, chills & sweats) in attacks at about 9 days intervals!- and some measures the doctor may do in the clinic - and some known possible triggers of symptoms.
Then all "pieces of the puzzle" can be evaluated together and make it easier to notice what is common features of the "disease picture" under investigation.
Most import, all symptoms, the course of disease over time, plus effect (wanted as well as side effects) of treatment trials becomes VERY WELL DOCUMENTED and not forgotten.
We can always compare later events to previous events, when we have saved the diary!
The degree of disability can be read directly from the total symptom score! - total score / 3 = number of symptoms that are so severe that the patient is unable to function!

The many symptoms you CAN score in the diary may overwhelm you at first glance - but don't despair - because YOU NEED ONLY PUT SCORES IN FOR SYMPTOMS THAT YOU HAVE - i.e., symptoms which are ABNORMAL, i.e. ABOVE ZERO.  
Except for temperature and pulse
(potential flare markers, when you suspect that a CHRONIC INFECTION cause your symptoms), and at least one height and weigth (necessary to calculate sufficient dose of drugs)-
YOU DON'T have to measure everything every day, nor continue measuring it all for years, just do it long time enough to be able to spot the "basic level" before eventual intervention (1-3 months) and if there is a regular flare activity pattern, which of course depends on the type of disease.
IF your temperature measures are lying stabile within normal range for about a month and do not show any visible flareswings, you can stop the daily measures and only do controls, if you later feel abnormal / changed.

But - because we need to take
eventual cyclicity
into consideration, when chosing the best time for drawing blood for ANTIGEN TEST, you should not stop the diary until you have a plan for testing / permission to stop the diary from your doctor!
The slower the growth velocity of microbes the longer observations time is needed to judge both spontaneous untreated course and result of treatment!

Sometimes exposures to environmental toxins (molds) or toxins in food or known allergens can elicit an immune reaction and may even cause a FEVER and thereby imitate an INFECTION.
Therefore I added some of the more common exposures to known toxins, including some that some people use out of free will as stimulants, like tobacco, coffee and alcohol! - that may cause or aggravate some of the symptoms - in that case you should abstain from continuing the use of the suspected trigger, at least for a while, and then read the result of the pause, on the symptom score! 
You may add extra triggers, when you suspect they could have influence on some of your symptoms!

I tried my best to make the symptomscore chart easily adjustable to accomodate to individual needs and to become usable for all sort of chronic conditions / following any treatment trial, whether conventional or alternative. However if you add something, calculation and curves also need to be added manually, if to be shown on curves too - this is not a "do-it-yourself" matter as described above, unless you are very familiar with Excel!

IMPORTANT NOTES before you begin registering your symptom scores:
IMPORTANT NOTES when filling data into the SYMPTOMSCORES spreadsheet:
In your personalized version in SYMPTOMSCORES columna A, you enter all drug names, the prescribed dose (mg/tbl, mg/ml) and number of times per day to take the doses:
ex: T. metronidazole 500mg x 2    or    bricanyl mixture 0,3 mg/ml, 5 ml (1,5 mg) x 3.
UNDER THE DATE SUM UP ALL DOSES TAKEN THAT PARTICULAR DAY without text! - if you add "mg" after the number, curve will not be drawn!
ex. metronidazol: 1000  (~ 500*2)   or   bricanyl mixtur: 4,5  (~ 1,5*3)
Supplementary treatment is entered likewise as for presciption drug, when possible! - it is VERY IMPORTANT TO REPORT EVERYTHING TAKEN, also non-prescription drugs like painkillers ....
If the immune function is reduced due to toxic reaction and/or detoxification is generally hampered by lack of essential nutrients (vitamins and minerals are important co-enzymes, lack of which may reduce / block enzyme function => bottle neck in the detoxification pathway), then we can expect worse side effects and may need to START WITH REDUCED DOSE and SLOW INCREASE after any reaction has passed, in order to avoid too fierce worsening reaction! 

You should have scientific data present about all alternative drugs that you use and give your doctor a copy, because some natural herbs may actually interfere with metabolism of prescription drugs (increase or slow detoxification) or may cause known side effect / bad interactions with other drugs that you take, that could perhaps explain some of your symptoms.
There are many possible alternative treatments it could be interesting to register IF there is positive effect of: physiotherapy, massage, chiropractic, zone therapy, physical training (note what, duration and grade in PT-notes) etc. etc.! 
NEVER START A NEW SUPPLEMENT / TREATMENT without first discussing with your doctor, if it interferes with other things you take and may give unwanted adverse effect.
When a patient is multi-medicated, is becomes very difficult to judge which effect / adverse effect comes from which single / combination of preparation(s).

Trial treatments should be planned in such a way, that we are able to read the effect from that intervention specifically in the symptom diary - i.e. preferably keep everything else un-changed!

A "spontaneous" improvement can occur when a bug goes into latent stage without any known reason, or could perhaps be result of a lifestyle change the patient made; we'll need several patients - that are comparable in duration of disease, severity, known causes, age, sex etc. etc. - that try the exact same intervention, in order to compare results / pool data and find out if an improvement was most likely coincidental (few react the same way) or if it could be a treatment effect (most react the same way).
When using the diary before during and after an intervention, the patient can act as his/her own control for example by cross-over - i.e. a period without treatment / exposure to trigger can be compared to a period on treatment / exposure to trigger and again another period without / without treatment / exposure to trigger. If the reaction is consistent on/off several times, we probably see the result of the intervention.
NOTE do not make these shifts in intervention without discussing it and plan it all with your doctor; some drugs need pretty long time to show full effect, and some drugs show adverse effects in the beginning that may reduce along as the detoxification system adjust enzyme level to clear the drug (tolerance development); some drugs may create dependence, i.e. the patient can get withdrawal symptoms; in such cases the intervention must be gradually induced or retracted.
(you can change description if you need to! - but then you can't compare with other patients scores and your doctor can not compare your data with others, make it more difficult to judge your situation!)
NOTE 0: NORMAL CONDITION may be explained in []

DON'T WRITE ZEROs (normal condition) INTO the SYMPTOMSCORES, only scores >0. ZERO is automatically assumned, when a cell is left empty!]

Toxin / allergy / diet-break EXPOSURES must be noted:
Explain in PT-notes what, when, how long, how much, and describe you reaction with words.
ALLERGY-like reaction:
1: non-characteristic, but reproducible reaction after contact with the toxin / allergen
2: localized hives / excema without breathing difficulty (asthma) or circulatory disturbance
3: generalized hives or severe excema, and/or asthma and/or circulatory disturbance (shock)

1: slightly sensitive; a single glass of beer or wine is tolerated, but reaction to less than usual for you (explain how much you usually tolerate). 
2: moderately sensitive: feels intoxicated after a little cider or a low-alcohol beer
3: very sensitive; no alcohol tolerance, you can even feel sick / intoxicated after smelling alcohol or perfume (~multiple chemical sensitivity)
General wellbeing/malaise, other symptoms not related to specific organ systems, functions
Swollen glands:
- describe in PT-note which glands are swollen and size
[0 = no]
1 = yes

Chills- and sweats - feeling cold (may be important infectious symptom flare markers)

- during a flare, please measure temperatures several times that day at 2-4 hour intervals, because sometime temperature changes may occur quickly as fall/rise during 6-12 hours!
1: cold without sweats or warm without chills
2: chills, feeling cold, need more clothes on to get warm, than other people in the same environment OR feeling hot, but not with drenching sweats
3: very cold and feeling multiple chills after another, cold hands and feet; have to take a warm bath/ sauna and go to bed with clothes on to warm up, later break out in drenching sweats

Colour of skin (paleness / redness)
1: short attacks of redness or paleness
2: redness / paleness of longer duration (noticed by others),
3: very pale / gray / bluish tint OR red flushing tint (perhaps as Harlequin phenomenon (one-sided))

1: a little tired, clears after a short pause / rest
2: moderately tired, need to rest/sleep one or more times during day time
3: extremly tired / exhausted, need to rest all the time during day time

Disturbed sleep pattern:
[0: normal (at least 6 hours sleep in a row during the night)]
1: sleeping less than (<) 6 hour in the night, but is relatively rested in the morning - need to have a nap in the afternoon
2: sleeping only short time in a row, turning around night and day, not rested in the morning despite min. 8 hours sleep per 24 hours
3: sleep only minutes at a time, don't sleep at all or sleeps more than (>) 12 hours per 24 hours.

0,1-0,9: Spot-bleeding
1: normal menstruation
2: bleeding more than normal
3: excessive bleeding

Perimenopausal females only:
Actual number of heat waves per day (short duration i.e. seconds to a few minutes)

[0: normal = no appliances needed, walking distance 500+ meters]
1: using a cane or walking distance in range 100-500 meter
2: using a rollator or walking distance less than 100 meter
3: using a wheelchair / bedresting / walking distance 0 meter

Need of nursing:
[0: no need for help]
1: need help with domestic work, cleaning etc. - describe in notes what you need help with and what you can do yourself
2: need a little help with personal care
3: need extensive help with everything
(if problems: write Right / Left in PT notes and do Functional Acuity Contrast Test (FACT) or VCS at http://chronicneurotoxins.com )
Light sensible: 
1: slight, but no need for sunglasses
2: moderate, uses sunglasses in clouded weather and indoor
3: severe, can't stand light at all, must wear very black (noir) sunglasses / mask

Blurred vision:
1: slight, letters blurred but can read
2: moderate, letters more blurred, difficult to read
3: severe, everything grey in grey, can't read letters

Double vision: 
[0: no]
1: yes

Night vision:  (check for A-vitamin deficiency)
1: slightly decreased discrimination, tiring to drive car in twilight and dark
2: moderately decreased, can't read roadsigns in twilight / dark
3: severely decreased, everything blurred, unsafe to drive car

Estimation of / ability to judge distance:
[0: good, normal]
1: bad, difficult

Floaters ("mouches volantes") inside the eye:

1: a few
2: a lot
3: many

Red eyes, secretions, pain (conjunctivitis):
1: slight irritation, no redness
2: moderate irritation, slight dry secretion, slightly red conjunctival vessels
3: severe irritation, pus, very red (bloodshot) eyes, pains
Ears, sinus cavities:
(if problems: write Right / Left in PT-notes)
1: slightly decreased
2: moderately decreased, hardness of hearing, difficult to understand speech
3: deaf

Sound sensible:
1: slightly sensible, no difficulty hearing talk
2: moderately sensitive, have trouble hearing what others say, when in a room with much noise, like when many people talk at the same time or TV/radio is turned on
3: severe, can't stand noise / talk, have to wear earplugs

- describe character of the sound in PT-notes
1: short tones (lasting seconds to minutes)
2: tone lasts over 1 hour
3: tone constant, allways present

Ear pain: 
1: slight - painkillers can remove the pain
2: moderate - only slight effect of painkillers
3: severe - painkillers don't help at all

Tuba occlusion / like having an earplug closing the auditory canal:

[0: no]
1: yes 
Nose, discharge, airway passage:
[0: normal, free airway in both nostrils]
1: slightly swollen mucous membranes, but airway passage - if discharge/snot, describe looks of it (clear/yellow muddy, thin/thick, +/- blood)
2: moderately swollen mucous membranes, passage closed fully in one nostril at a time, partial passage in the other
3: both nostrils closed for air passage all the time, breathe through open mouth

Sense of smell / olfactory sense:

1: slightly reduced
2: moderately reduced
3: severely reduced, no sense of smell
Chest area, heart, lungs:
[ PULSE = number of heartbeats per minute must be entered under measures (Normal range 60-80; over 100 tachycardia, below 50 bradycardia) ]

Number of attacks of irregular heart beats

Number of missed heart beats/block:
1: slightly abnormal; a few missed beats, duration less than 5 sec. - write in PT-notes if extrasystole was seen on ECG
2: moderately abnormal; pulse 40-60, or pulse stop for 5-15 sec.
3: severely abnormal (dangerous, life-threathening); pulse under 40 or pulse stops for more than 15 sec (need pacemaker)

Minimal duration of heart arrhytmia (minutes)

Maximal duration of heart arrhytmia (minutes)

1: slight - short stings / shooting pains
2: moderate, feeling of oppression  / weight on the chest, difficulty taking a deep breath due to pains
3: severe pain in heart / angina pectoris

- note describe dry or wet in PT notes
1: slight - a dry irritative cough, sometimes, write number of attacks per day in PT notes
2: moderate - wet cough, about every hour, slight clear expectoration
3: severe - wet cough several times per hour, a lot of think slime or suppurative mucous

Breathing difficulty / short of breath:
[0: normal, speaking effortless even when walking fast / running]
1: slightly short of breath after physical activity, but can speak
2: moderately out of breath, can not speak while walking slowly
3: severely breathless /dyspnoeic, gasping for breath, wheezing, difficult to speak even when not moving

Respiratory pains:
1: slight, only shooting pains on deep breath or special movements (nerve pain) 
2: moderate, pains at every breath
3: severe, dare hardly breathe because of the pains


1: slight, deklive (foot and ankle, fingerpressure (shin) less than 1 cm deep)
2: moderate, deklive ex. to middle of shin (evening), maybe also eyes, fingers (morning), finger pressure (shin) 1-2 cm deep
3: severe oedema, deklive to knee or above in the evening, eyes and fingers (and scrotum) still swollen part of or whole day, finger pressure (shin) more than 2 cm dybt
Mouth, Stomach, Intestine:
Sore throat/pharyngitis:
1: slight -  stinging / irritation irritation, but not nedness nor coating
2: moderate - pain when swallowing, redness, but not coating
3: severe - pain when swallowing, very red and coated mucous membranes (describe in PT-notes)

Sense of taste:
1: food tastes a little diferent / or reduced
2: metal-taste, food much different
3: rotten or metallic taste all the time 

Blisters, aptheae in mouth or throat:
1: a few (1-2)
2: a lot (3-10)
3: many (more than 10)

1: slight - can eat, relieves nausea a bit
2: moderate - eating difficult, doesn't relieve the nausea
3: severe - can't eat, results in vomiting when trying

number of times per 24 hours

Bloating, belly aches, abdominal cramps, heartburn:
1: slight bloating, abd. pains occurring less than 10 times per 24 hours
2: moderate (visible) bloating/distension, loud bowel noises (borborygmi), abd. cramps more then 10 times, but not every hour
3: severely inflated, loud bowel noises with crisp, tingling sounds, cramps severel times per hour

number of times per 24 hours

Stool consistency:
[0: wellformed]
1: hard
2: very soft and bulky (porridge like)
3: watery

Stool incontinence:
number of incontinence episodes per 24 hours

1: increased, eat more than normal (bulimia)
2: decreased, eat less than normal / needed  (slight anoxexia)
3: no appetite, eating difficult (severe anorexia)
Urinary tract:
Irritable bladder / pain::
1: slight urge - bladder / urethral irritation / burning, need for frequent urination, but can control it
2: moderate urge -burning/stinging painful urination, must pee all the time despite little urine to pass, can't control it
3: severe urge - bladder cramps/very painful, burning urge plus urinal discharge, bloody urine

Urinations during daytime (06-24):
number of urinations
Urinations during nighttime (24-06):
number of urinations
NOTE if abnormality in frequency of urination and/or in amount excreted (normal average is 1500 ml urine per day) we must have details about what/when (3 days):
    measure both your fluid intake (milliliter & time), and amount & time per urination;
    after 24 hours; calculate sum of intake (excessive (~ (psychogenic?) diabetes insipidus) if intake is in range 6-10 liters per day) respectively sum of excretion and compare
   since we use some water for metabolism and lose some through sweat (more in warm weather and fever) excretion should be less than intake of fluids.
   * a very low intake of fluid (less than 1 liter/die) respectively * excessive drinking (polydipsia >3-4 liter/die) will influence the amount of urine produced; excess is excreted; 
   * increased glomerular filtration rate occurs during fever and hyperthyoidism; * decreased reabsorption of water in distale tubule (kidney damage)
   * diabetes insipidus:  lack of antidiuretic hormone (ADH, vasopressin) a pituitary hormone that normally peak during night time, cause kidney to concentrate the urine (so sleep is not disturbed),
   hence damage to the pituitary (tumor, inflammation, toxins) can cause lack of ADH and result in frequent, large urinations, because urine can not be concentrated without ADH
   => loss of water causes thirst; Addis thirst test, urine excretion stay on same high level despite fluid intake is reduced / paused totally; urine osmolarity do not increase as normal during thirst
   * increased excretion of solutes will draw water out: salts, loss of albumine though kidney (due to damage to glomeruli) or high sugar (diabetes mellitus) in urine and diuretics can cause increased urination
   * some herbs and alcohol also increases urinary excretion!  

Urine colour / cloudyness:
[0: clear, light yellow]
1: slighly unclear 
2: cloudy, colour abnormal
3: bloody / very cloudy (can't see through it)
- whenever urine looks abnormal, describe how it looks, and if is smells?
There are numerous causes of abnormal coloration of urine, food and drug can affect it very much!
- urate and other salt crystal can precipitate in concentrated urine can result in cloudy urine or stone formation (do you drink enough?)
If urine darkens when left in the bottle over time plus patient has abdominal pain, nerve pains and skin problems (photosensitivity, blisters) - then suspect porphyria?
- porphyria can be intermittent and attacks can be provoked by many triggers, among which are infection / drugs (certain antibiotics) ... 

Urine incontinence:
number of leaks per 24 hours
Musles, joints, bones:
- decribe where and how in PT-notes
Neck & Back:
1: slight pain, non-irradiating, slight stiffness
2: moderate pain, moderat stiffness, creaks and cracks
3: severe pain, movement reduced or locked / pinched nerve / fact syndrom like / lumbago

1: slight pain, no objective changes 
2: moderate pain, slight swelling (may be due to peri-oedema) revert to fully normal in silent phase
3: severe pains, redness and warmness over affected joint(s), fluid in joint, synovitis (changes may persist to some degree after acute exacerbation) 

Muscle pain, "acid feeling":
1: slight pain, acid feeling develops after moderate exercise, requires hours rest
2: moderate pain, acid feeling ved slight exercise (ex. sore leg muscles after <500 meter walking distance), requires days rest
3: severe pain, tired, sore, acid feeling all the time without exercise, not relieved by rest for days

Muscles - cramps, fasciculations, twitching, tremor, wobbling, clonus, jerks:

1: feeling of slight movement, not objective / not visible by others 
2: objective tremor, fasciculation, jerks 
3: clonic/tonic cramps (- remember to describe level of conciousness during attack and duration in PT-notes)

Muscle weakness, paresis, drop attack:
1: feeling reduced force, but not objectively reduced
    drop-attack: a sudden involuntary unexpected loss of muscle tone when in legs leading to a fall (or in hands dropping things), without loss of conciousness, that is over in seconds or a few minutes
    - describe in PT-note
2: paresis, objectively reduced force, but the muscle / limb can be moved by the patient
3: paralysis, limb can not be moved by muscle force

Morning stiffness (joint, muscle):
[0: no]
1: yes
- describe where and how long and what helps in PT notes

Bone pain:
- is usually deep, penetrating, or dull.
1: slight, few stabbing pains of short duration (seconds)
2: moderate, pain lasts minutes to hours
3: severe pain, present all the time
Skin pain:
- burning, stabbing - describe type and location in PT-notes
1: slight but short lasting (minutes) burning pain after touch 
2: moderate burning, longer lasting than normal (hours) after even a slight touch, that should not hurt normally
3: severe burning (like a severe sunburn) present all the time

Reduced sensibility:
- prickling, numbness - describe location in PT-notes
1: slightly reduced - slight numbness and prickling, but can sense touch (that may elicit burning)
2: moderately reduced - numbness and prickling, reduced sense of warm and cold touch, reduced sensibility for needle prick
3: severe numbness, can't feel anything on touch

- describe localisation in PT-notes
1: slight itch, can abstain from scratching 
2: moderate itch, disturbing, need to scratch
3: severe itch, all the time, very disturbing, can't sleep for it, scratching marks on skin, if long term may lead to leathery thickening (lichenification)

Rash (non-hemorrhagic) or sores:

[0: no]
1: yes
- describe localisation, appearance/color, size and duration TAKE PHOTO (with ruler besides) when possible

Hemorrhagic rashes:
- describe localisation, appearance/color, size, consistency (if felt) and duration - TAKE PHOTO (with ruler besides) when possible
1: few and tiny, (pinpoint petecchiae), occurs mainly after scratching or pressure applied to the skin
2: a lot, small mm size spots (vasculitis like) to larger (more cm) sugillations, occurs spontaneoulsy on arms and legs especially declive, but rarely on truncus
3: many spontaneusly ocurring bleeding spots of various size, overall but mostly extremities
Brain, Neurological symptoms:
- describe localisation in PT-notes
1: slight - mental function reduced, but possible to "pull yourself together", physical strain makes headache worse
2: moderate - can't think or work, must rest - but able to be up and can eat 
3: severe - migraine like - can't do anything, bedridden - headache usually accompagnied by other "neurotoxin" symptoms like light- and sound sensibility, nausea, sometimes vomiting

Shooting pain / lightning / stabbing pain:

- describe localisation in PT-notes
1: a few times a day
2: once per hour
3: several times per hour

Brainfog / like being in a glass case:
"Brainfog may be described as a state of confusion or lack of clarity.  It can feel like a cloud that reduces your visibility or clarity of mind. It can cause you to become forgetful, detached and often discouraged and depressed."
1: can't concentrate on following conversation if something else distracting is going on nearby, like when many others are talking, background noise (get foggy at party, in a shopping mall)
2: can't concentrate on following conversation, even when quite and only one person is talking to you at a time
3: do not understand anything, feel like being in another world / outside oneself / spectator to a silent movie; 'flickering on TV' the meaning do not pass into the brain / is not perceived

Disorientation / getting lost, going to wrong places:

1: slight problems finding way in unknown plaves, but can understand and follow directions
2: moderate problems finding way in known places, problem finding out which direction one is going
3: gets lost even in wellknown places, enters the neighbors door instead of ones own door

Concentration difficulty:

1: slight problems sticking the mind to try solve a difficult task (work), but can do relaxing things like watching entertainment in TV, read magazine
2: moderate - can concentrate on easy things like entertainment in TV, but can't concentrate on reading a book nor follow the plot in a detective story; can't stick to solve a task, but is easily distracted by interruptions and can't pick up and continue with solving the task after the break
3: severe - can't concentrate on anything, even not light entertainment / comedy, can't read and understand even a few lines of text in a magazine

Memory problems (usually short term):

1: need help from writing notes, calendar, alarms to remember appointments and have "post-it" everywhere, in order to remember what to do, remember to buy etc. - but with these aids can function pretty normally (i.e. others may not notice you have memory problems); you have no problems remembering your PIN codes to different credit cards or your familys and friends phone numbers that was learned before, but can have much trouble learning new numbers
2: can't keep track of anything without notes (but forget to look in them), forgets wellknown routine things link PIN and phonenumbers, if going for something but comes back without, several times … i.e. all tasks are done slow, bad and usually with many repeated trials before success (your credit card may get closed because you continue entering wrong PIN numbers).
3: can't tell what you was told 5 minutes ago, have difficulty remembering how to do common tasks, maybe can't remember what your own notes mean, i.e. unable to do activities of normal daily living, thus need help from others

Difficulty with finding words / spelling / word search / name block:
1: slight problems - make letter / numbers reversals, but notice and correct during proof-reading, no problems with forming sentenses or finding words
2: moderate problems ....
3: severe problems finding words (may try forming new words as replacement), sentences backwards, many letter reversals / spelling errors, which is not found despite more proofreadings ..

Perception / comprehension / ability to understand meaning of what is written / said:
1: slight problems - can understand simple messages, but have problems grasping the meaning of more complex explanations
2: moderate  problems ....
3: severe problems - can not understand even simpler messages

Dizziness / poor balance:
1: slight - dizzy spells / sense of nearly fainting - of few minutes duration and only a few timer during 24 hours
2: moderate - feeling drunk / intoxicated / dizzy spells comes several times a day and/or lasts for hours
3: severe vertigo - feeling like the room is spinning around or like the floor is moving up and down under your feet
Low self esteem:
[0:  I'm okay and believe in myself]
1: slight - I realize there are things I can not do anymore, but the illness gives a natural explanation for why, and no matter what others say, I know the cause of my problems is not a mental illness.
2: moderate - there are many things I can not do, others are partially right when they say it is psychic
3: severe - I am no good at anything, others are always better and always right, I believe them when they say I'm depressed

Mood swings - cyring spells:

[0: no]
1: yes - describe the situation in PT-notes

Suicide thoughts:
[0: never had]
1: slight - rarely and can be talked out of it / can alter my negative thoughts by intentionally thinking positive, thinking "what could be worse"
2: moderate ....
3: severe - thinking life is way too difficult to live on, as it is now, have thought on how to commit suicide  

Irritability, lack of impulse control, "short fuse":
1: slight - 'short fuse' and feeling irritable within, but without leading to uncontrolled, unsuitable actions
2: moderate - you have temper tantrums, scream at others, but can stop yourself before violence or destruction
3: severe - lack of impulse control, leading to uncontrolled, unacceptable actions, like violence or destruction

1: slight - only occasional fear which can be controlled
2: moderate - fight hampers functions out of home, but you manage quite well at home
3: severe - anxiety / fear hampers all functions, everywhere

Sexuel function - desire/libido, ability:
- describe in PT-note
1: slightly abnormal - increased desire and able to perform normally  
2: moderately decreased libido, but can perform coitus
3: severely decreased libido / ability, can not perform coitus