1— Overall quality of Sleep    1 2 3 4 5 6 7 8 9 10

  • sleep efficiency Hours (laying down ratio to sleep amount) _______
  • feeling rested upon awakening  1 2 3 4 5 6 7 8 9 10
  • up in middle of night  y/n
  • have to pee how many times per night     0 1 2 3
  • bedtime hours  go to sleep________, wake up___________

 

2—Energy level during the day? (Mental and physical.)

  • 1 2 3 4 5 6 7 8 9 10

3—Circadian scheduling

timing of meals breakfast_____, lunch_____, supper,_____, snacks______

4—Feeling of well-being. 1 2 3 4 5 6 7 8 9 10

5—Weight loss_________, or gain___________

 

6—Bowel movements per day average. 1 2 3 4 5

 

7–Pain of any sort? _______________________________

 

8–What is your biggest issue this week? _____________________

 

9—Temp. ____________, Pulse_______________

 

10—Success with following the diet (what percentage did you deviate?) ____

 

11—Satisfaction or issues with the diet _________________

 

12—Exercise type?__________ Amt./day?__________Times/wk?_________

 

sleep checklist

EMFs, use of artificial light, is room dark?, last meal 4-5 hours before bed, toxins in bedding and bedroom, N.E.A.T. (how many hours sitting?), exposure to sunlight, walking on the earth barefoot, Cold Thermogenesis, exposure to chemicals or mold during the day or in the bedroom.