STUDY DRUG DIARY TEMPLATE (One Drug) - Modify the diary to meet the specific needs of the study. Remember to delete all instructions, i.e., blue
text - these statements are provided for guidance only.
OTHER MEDICATIONS TAKEN Study Participant
If you take a daily medication (prescribed or otherwise), please use one Study Drug Diary
line per drug and indicate the start and stop dates under the "Date(s) Dana-Farber/Harvard Cancer Center
Taken" section (i.e., 6/2/09 - 6/5/09).
Drug Name Dose Dates Taken Reason Taken Participant Identifier: ____________________
Protocol # : Insert DFCI IRB protocol number
Your MD ____________________ Phone ____________________
Your RN _____________________ Phone ____________________
STUDY DRUG INSTRUCTIONS:
Study Drug: Insert drug name
How Much: Your dose is enter the amount and units.
How Often: You will take each dose ….
When: You should take your dose ….
Study Participant Initials __________ Date _________ List any special drug instructions. When appropriate, include:
(i) exclusionary food or beverage item; (ii) storage requirements;
(iii) mixing instructions; (iv) what to do with late, missed or vomited
FOR STUDY TEAM USE ONLY doses; (v) information related to safety concerns; and (vi) a statement
that drug must be kept in original container.
Date Dispensed: Date Returned: End with a reminder to bring any unused study drug, all empty
# pills/caps/tabs dispensed: # pills/caps/tabs returned: containers, and diary to the next clinic visit.
# pills/caps/tabs that should have been taken:
DOSING LOG SYMPTOMS/SIDE EFFECTS
Insert study drug name
Cycle: ___ For each AM dose take: # pills/capsules/tablets Please record any side effects experienced during this cycle.
For each PM dose take: # pills/capsules/tablets Include the date the particular symptom started and when it
ended. Please evaluate the severity of the symptom according to
Please indicate the date, time, amount taken and any comments. the following scale:
Amount Taken Mild: Awareness of sign or symptom; easily tolerated and did
Date AM dose PM dose Comments not affect ability to perform normal daily activities. Symptom
Ex: 6/1/2009 8 am - 1 7:30 pm - 1 vomited PM pill did not require medication or therapeutic intervention.
Day 2 Moderate: Significant discomfort which interfered with ability
Day 3 to perform normal daily activities. Symptom was easily resolved
Day 4 with at home medication or simple therapeutic intervention.
Day 6 Severe: Marked discomfort with an inability to carry out
Day 7 normal daily activities. Symptom required new medication
Day 8 and/or therapeutic intervention in order to resolve.
Day 10 Please Note: The severity should reflect the most severe level
Day 11 experienced during the time period.
Day 13 Symptom Start Date End Date Severity