Treatment Checklist (HTN)

Recommended Treatment for ___________________________:

Current Medications:
Medicine
Dosage

Schedule

Check when dosage was taken

Monday Tuesday Wednesd Thursda
ay
y
am/pm
am/pm
am/pm
am/pm
am/pm
am/pm
am/pm
am/pm
Record your blood pressure
Date:
/
Date:
Time:
Time:

Friday
am/pm
am/pm

Saturda
y
am/pm
am/pm

Sunday
am/pm
am/pm

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Date:
Time:

Make note of your side effects

Side effect description
Date first
noticed

Notes (duration, management,

tips you have tried)

Keep in touch with your healthcare team

This checklist is meant to help you stay organized during treatment.

Patient signature: ___________________________________________

Date:

________________
Volunteer signature: ________________________________________ Date:
________________