Vigene R&D Food Diary
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Transcript of Vigene R&D Food Diary
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
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________