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CHARTS Evening Diary

CHARTS Evening Diary

Did you forget today's Morning Diary? If so, CLICK HERE and complete it.
3. If you DID take a nap...
How long? (leave blank if none) What time? (leave blank if none)
Nap 1
Nap 2
Nap 3
5. Approximately how many MINUTES did you spend... *This question is required.
*This question is required
*This question is required
8. Please list all caffeinated foods/drinks you consumed today, along with time of day:
Type (leave blank if none) Brand (leave blank if none) Amount (leave blank if none) Time of day
Caffeine 1
Caffeine 2
Caffeine 3
Caffeine 4
Caffeine 5
Caffeine 6
Caffeine 7
Caffeine 8
Caffeine 9
Caffeine 10
10. Please list all relaxing foods/drinks you consumed today, along with time of day:
Type (leave blank if none) Description (what was it?) Amount Time of day
Relaxing 1
Relaxing 2
Relaxing 3
Relaxing 4
Relaxing 5
Relaxing 6
Relaxing 7
Relaxing 8
Relaxing 9
Relaxing 10
12. If YES, how many did you smoke in the...
14. If YES, how many drinks did you have in the...
16. If YES, what did you take, and when?
Space Cell NameDoseTime takenTaken for what?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
17. Did you take any vitamins/supplements today (include ones you mentioned already)?
Space Cell NameDoseWhen takenPurpose
Supplement 1
Supplement 2
Supplement 3
Supplement 4
Supplement 5
Supplement 6
Supplement 7
Supplement 8
Supplement 9
Supplement 10
18. Were any of these medications or supplements taken in order to:
19. How much time did you spend today... *This question is required.
*This question is required
*This question is required
*This question is required
*This question is required