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)

SYMPTOMS LOG: (rate 1-10: 1=best / 5=average / 10=worst)

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