# Symptom and exposure record

Use this record when discussing new symptoms after methylene blue with a clinician or pharmacist. Describe observations without assuming die-off, detoxification, or another diagnosis. Do not delay urgent care to complete it.

## Product and exposure

| Field | Your record |
| --- | --- |
| Product name and manufacturer | |
| Lot number and expiry | |
| Formulation and concentration exactly as labeled | |
| Route used | |
| Amount used, including units and measuring device | |
| Each exposure date and time | |
| Recent change in product, amount, or frequency | |
| Label photograph available | |

## Symptoms

| Symptom in ordinary language | First noticed, date and time | Severity and effect on activity | Improving, unchanged, or worsening |
| --- | --- | --- | --- |
| | | | |
| | | | |
| | | | |
| | | | |

## Clinical context

| Field | Your record |
| --- | --- |
| Prescription medicines, doses, and last taken times | |
| Nonprescription medicines, cough products, and supplements | |
| Relevant diagnoses or known allergies | |
| Known G6PD result, with date if available | |
| Any clinician-directed infection treatment | |
| Anything taken or done after symptoms began | |
| Clinician or pharmacist contacted and advice received | |

Call emergency services for difficulty breathing, collapse, seizures, severe confusion, or a rapidly worsening reaction. Do not take another self-directed dose to test the cause. Do not independently change prescribed medicines to continue methylene blue.