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Treatment Calendar


HoG Treatment CalendarYou can print your treatment calendar at home. Keeping accurate records of bleeds, infusions, and other medications can help identify patterns and help prevent future problems. Completed treatment calendars may also be helpful for insurance issues.

How to use the Treatment Calendars

The Hemophilia of Georgia Treatment Calendar is available as a PDF file and as a Microsoft Word document. If you use Microsoft Word you can save the Word document on your computer and then type in your treatment information. If you don’t have Word or would prefer to write on the form instead of typing, just print out the PDF file.

What Information to Put On the Calendar

The Treatment Calendar includes space for you to record the date of each treatment, the name, lot number, and expiration date of the product you used, and the amount of medication used. Sometimes, this information is included on a removable label on the vial of clotting factor.

In the box labeled Prophylaxis?, please write Yes if the treatment was a regular, routine infusion or write No if the treatment was for an injury or bleed. In the box that says Current Bleed? Where?, please write Yes if the treatment was needed because of a bleed. And, if it was, please indicate the location of the bleed, such as right elbow or left ankle. In the box that says Pain Scale, please indicate the level of pain associated with bleed or injury, if any, on a scale of 1 to 3, with 1 being the lowest pain level. Finally, in the last box, please write in the name of the person who gave the infusion. If it is a self-infusion, please write self.

Monthly Calendar

If you'd like to stick the label from your factor vial on the calendar, please use the Monthly Calendar pdf.

What to Do with Completed Calendars

Once you’ve completed your treatment calendar, it can be sent or taken to your Hemophilia Treatment Center. Please talk to the HTC nurse to find out about faxing or emailing your calendars.