The Johannesburg Infusion Centre

Patient Iron Symptom Form

Complete the symptom form with a score from 1–10, then download or Whatsapp the PDF to us. You can also upload a previously downloaded PDF to continue with your 6-week entry.

Privacy notice: all data entered in this form is stored in this browser only. When sharing the results of this form via Whatsapp, you agree to share the information captured here with The Johannesburg Infusion Centre.

1. Restore an entry

Upload a previously downloaded PDF here to continue or load previously saved data from your browser. Alternatively start a new form below.

- or -

Current document state

First entry
Not added
Second entry
Not added
Follow-up date
Not set

2. Fill out or edit an entry

New entry mode

Symptom scores 1 = low/not present, 10 = high/severe

3. Saved Entries

Each chart is created and saved when its entry is saved. Use the edit buttons to change the values and edit a saved chart.

Entry 1 Chart

Entry 2 Chart

4. Create PDF

The generated PDF includes hidden recovery JSON with each entry and its saved graph image, so the same PDF can be uploaded later for the 6-week follow-up.