Lifestyle Medicine Diary

R&D

Lifestyle Medicine – Lifestyle Diary Day ____ Date: ______________ ( )

Supplement Time Food Quantity Dietary/ Supplement Feedback/ Remarks

Fish Oil ___ cap. UltraFlora ___ cap. Endefen ___ Scoops UltraClear ___ Scoops Phytoganix ___ Scoops

BF

MT

L

AT

D

Sleeping Time: From _____ To _____

Sleeping Quality: 1 2 3 4 5 Insomnia/Dreams/Wake-up/Others_______

Water Intake: ______ Cups Menstruation: Day ______

Exercise: _____________ x ________ mins

Mood: 1 2 3 4 5 Stress: 1 2 3 4 5

Bowel:

Stool Form(refer to appendix):

Colour:

Texture:

Digestion:

Bloating (Gases):

Peristalsis:

_____ Times

Type 1 2 3 4 5 6 7

Watery / Watery with lumps / Smooth / Firm / Hard

Poor 1 2 3 4 5 Good

Less 1 2 3 4 5 Much

Poor 1 2 3 4 5 Good

Supplement Time Food Quantity Dietary/ Supplement Feedback/ Remarks

Fish Oil ___ cap. UltraFlora ___ cap. Endefen ___ Scoops UltraClear ___ Scoops Phytoganix ___ Scoops

BF

MT

L

AT

D

Sleeping Time: From _____ To _____

Sleeping Quality: 1 2 3 4 5 Insomnia/Dreams/Wake-up/Others_______

Water Intake: ______ Cups Menstruation: Day ______

Exercise: _____________ x ________ mins

Mood: 1 2 3 4 5 Stress: 1 2 3 4 5

Bowel:

Stool Form(refer to appendix):

Colour:

Texture:

Digestion:

Bloating (Gases):

Peristalsis:

_____ Times

Type 1 2 3 4 5 6 7

Watery / Watery with lumps / Smooth / Firm / Hard

Poor 1 2 3 4 5 Good

Less 1 2 3 4 5 Much

Poor 1 2 3 4 5 Good

Dietary Compliance:

Supplement Compliance:

1 2 3 4 5

1 2 3 4 5

Lifestyle Medicine – Lifestyle Diary Day ____ Date: ______________ ( )

Signs/Symptoms

1

Severity 1 2 3 4 5 Time:

Event/Environment

2

Severity 1 2 3 4 5 Time:

Event/Environment

3

Severity 1 2 3 4 5 Time:

Event/Environment

4

Severity 1 2 3 4 5 Time:

Event/Environment

5

Severity 1 2 3 4 5 Time:

Event/Environment

Lifestyle Medicine – Lifestyle Diary

Notes/Remarks

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Signs/Symptoms

1

Severity 1 2 3 4 5 Time:

Event/Environment

2

Severity 1 2 3 4 5 Time:

Event/Environment

3

Severity 1 2 3 4 5 Time:

Event/Environment

4

Severity 1 2 3 4 5 Time:

Event/Environment

5

Severity 1 2 3 4 5 Time:

Event/Environment

Lifestyle Medicine – Lifestyle Diary

Notes/Remarks

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