SLEEP PATTERNS: (rate 1-10: 1=best / 5=average / 10=worst)
| Hours Slept: |
Depth (1-5): |
Refreshed (1-10): |
Minutes to Fall Asleep: |
Aware of Dreams: |
Aware of Sound: |
Aware of Movement: |
Aware of Time: |
Night Sweats: |
Rate Morning Stiffness (1-5): |
Sleep Aids Used: |
DAY LOG:
| Rate Your Day (1-10): |
Functionality: (100% a good day) |
Pain Index (1-10): |
Day's Activities: |
FOOD LIST: (list vitamin supplements and medications as well)
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SYMPTOMS LOG: (rate 1-10: 1=best / 5=average / 10=worst)
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EMOTIONAL: __ moodiness / irritability (1-10)_________ __ anxiousness / anxiety __ panic attack (when)________________ __ depression (when)__________________ (trigger)________________________ BRAIN & NERVE DYSFUNCTION: __ brain fog / disorientation / lack of focus __ headaches (when)__________________ sinus __ tension __ migraine __ __ twitches / tics / spasms (1-10) ______ (duration)_______________________ __ memory lapse (when)_______________ (what)_________________________ __ ear aches / noises (when)___________ (duration)_______________________ __ difficulty speaking / forgetting words __ paresthesia (numbness & tingling) (when)______(where)_____________ (cause)________(duration)_________ __ blurred vision (duration)_____________ __ fainting / shakes (when)_____________ __ disequilibrium / dizziness __ electric face / crawling skin __ carpal tunnel __ dropping things (for no reason) __ falling / buckling knees & ankles ALLERGIC REACTIONS & INTOLERANCE: __ asthma attacks ( # )________________ mild __ moderate __ severe __ __ puffy / itchy / red eyes __ rashes / eczema (where)_____________ __ acne / pressure pimples __ hives / fever blisters __ sound intolerance (what)_____________ __ light intolerance (what)______________ __ sight intolerance (what)______________ __ skin over-sensitivity __ smell intolerance (what ______________ __ taste intolerance (what)______________ __ cold sensitivity __extremities turn color ______________ (colors)_________________________ __ heat sensitivity |
DIGESTIVE & BLADDER DYSFUNCTION: __ gas / bloating __ loss or lack of appetite __ painful or burning urination / blood in urine IRRITABLE BOWEL SYNDROME: __ digestive irritation / pain (duration)____________ (location)_______________________________ __ stomach pain or cramping (when)_____________ (duration)_______________________________ __ nausea / vomiting (duration)_________________ __ constipation __ diarrhea BODY & GENERAL SYMPTOMS: __ sharp pains (when)______ (where)____________ __ muscle pain / stiffness (1-10)_________________ __ post-exhertion malaise (1-10) ________________ __ tenderness / bruising (where)_________ __ lymph node tenderness (throat & under arms) __ sudden fatigue / faintness (when)_____________ (where)___________ (causes)______________ __ sore / scratchy throat __ spitting up blood or mucus __ sinitus / clogged sinuses / post-nasal drip __ edema / swelling (where)_____________________ __ jaw pain/ jaw popping / jaw locking __ high / low blood pressure _____________________ __ low body temperature __ feverishness (like low-grade fever) __ heart palpitations / rapid heartbeat __ PMS severity / menstrual severity __ dysmenorrhea (painful menses) __ thickening / scaling skin __ unusual hair loss (more than usual) __ chest pains / costochondritis __ plantar arch and heel pain __ weather sensitivity (when)____________________ (duration)________________________________ (weather)________________________________ __ dry / gritty / burning eyes __ blind spot in vision / floaters __ difficulty swallowing / chewing (no saliva) __ swollen / cracked / unruly tongue __ excessively dry mouth / burning, sticky throat |