Form Hsls0021 - Home Phototherapy Treatment Log Template - Daavlin
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1Home Phototherapy Treatment Log
Patient Name_________________________________________ Date___________________
Comments (Record any problems such as itching, severity or location of
Pinkness
Severity
Treatment
Date
Dose
Time
any burning, technical difficulties, reasons for gaps in treatment, etc.)
(0-3)*
(0-10)**
Number
example m
No burn, slight itching after treatment.
1
0
4
1-1-15
300 mJ
2:00 min
Treatment Log Instructions:
* Pinkness Rating:
** Disease Severity Rating:
Please fill out this (or other similar journal)
0 = Not Pink
Patients, please rate your skin
to keep track of your therapy. Bring it
1 = Light Pink
condition on a scale of 0 - 10
with you to your follow-up appointments
2 = Medium Pink
where 0 is completely clear and
with your doctor.
3 = Dark Pink or Red
10 is the worst it has ever been.
HSLS0021, Rev 2, (1/16)
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