Habit Assessment Form and Process

CHANGING HABITS AND RECORD KEEPING
When you make changes in your habits, dietary pattern or supplements, be sure to write down the date and the following facts about yourself. You may copy this “chart” for self assessment, fill it out and circle what is true for you. (Make three copies, one to make new copies from without any markings, one for your first self-assessment and one for your second assessment after a period of changed behavior.)
Keep this with your health record or start a health record so that you, at least, can have a better idea of what helps you and what does not. If you have already decided to take a supplement on your own, please make a copy of your completed assessment to give or send to your health care provider/s. With the copy, include a written request asking the provider/s to review your plan and advise you if they see a problem with the plan.
You can monitor yourself by labeling the first assessment, “Signs and symptoms before change of (habit or supplement)” and date it. Keep one list to make copies for further personal “assessments.” On the other list, write down what you are going to do or to take as a supplement. After taking the supplement a while, at least two weeks, mark the second list with your “signs and symptoms after habit change or with supplement.” Then you can compare your first list with your second list to discover any differences between the two sets of signs and symptoms.
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Signs and Symptoms with / without a Supplement
Self-Assessment Record of __________________
Assessment date________ Before change___ After___
How you are feeling (glad, sad, mad, blah or no feelings), the condition of your hair (oily, shiny, dry, split or broken); skin (oily, dry, bruises, split, hangnails, slow healing); eyes (color of whites_______, dull, bright, bothered by bright light, dry, itchy, puffy, droopy); nails (split, brittle, limber, soft, white spots, ridges, break easily); joints (swollen, painful, noisy); sense of smell (sharp, dull, missing); sense of hearing (loud, startle, poor); location, kind and frequency of pain_________________________________; any problems with breathing___________________________; color of lips and mouth_______________________________, tongue color and texture______________________________,
problems with taste___________________________________; stomach and intestinal conditions (heartburn, gas, cramps, diarrhea, constipation, hemorrhoids); heart and blood pressure (changes in rhythm, faintness, leg cramps, swelling of hands or feet); problems of sexual sensation or performance______________________________, color and amount of discharges________________________; and changes in relationships, stresses and emotions.
_____________________________________________________________________________________________________________________________________________________________________
Plan for change (is or was) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Highlight or circle any differences or changes in your body and your feelings that have occurred since you started the supplements. Take your lists to your health care provider such as physician, nutritionist, or advanced practice nurse, and ask for advice regarding stopping, continuing, or changing your supplement

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