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Vigene R&D Food Diary
1.
Lifestyle Medicine Diary R&D
2.
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 _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
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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