Nuttall Brown & Coutts · Utah personal injury attorneys · (801) 255-2102
Use this page to make a brief, accurate record in your own words. It is not a diagnostic tool or a replacement for medical care. Follow your provider’s instructions and raise medical questions with the provider.
Print a fresh copy for each day, or use the headings in your own notebook. This page does not collect or save your answers online.
Daily entry
| Record | Your notes |
|---|---|
| Date and time | |
| Symptoms and where you noticed them | |
| Activities you could do | |
| Activities that were difficult | |
| Sleep or daily routine changes | |
| Appointments and provider instructions | |
| Medication taken as directed / questions | |
| Costs, missed work or access barriers | |
| Questions for your provider or attorney |
Make the record useful
- Use the actual date. If you are recalling an earlier day, identify it as a later recollection.
- Include better days and activities you could do, as well as difficulties.
- Distinguish what you experienced from what someone else told you.
- If you do not remember a detail, say so rather than guessing.
- Note practical barriers to appointments, such as transportation or scheduling, and discuss them with your provider.
- Ask an attorney how to store and share records containing personal health information.
Questions for the next conversation
If you have questions about the injury claim or documents an insurer requests, call (801) 255-2102 for a free case review. Medical questions belong with a qualified medical provider.
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General information, not legal or medical advice for your situation. Using a tool or contacting the firm does not create an attorney-client relationship.