1. Lifestyle Medicine
Diary
R&D

3. 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

4. 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: ______________ ( )

5. 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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6. 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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