Meniere's Sympton Triggers
Date
/
Month
/
Day
Year
Date
Weather
Temp - High
Temp - Low
Barometric Pressure
Pollen Count
Forecast
Sleep
Time Awake
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time To Bed
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Quality Of Sleep
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
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Diet
Breakfast
Total Sodium
Total Sugar
Lunch
Total Sodium
Total Sugar
Dinner
Total Sodium
Total Sugar
Snacks
Total Sodium
Total Sugar
Snack 1
Snack 2
Snack 3
Snack 4
Snack 5
Snack 6
Snack 7
Snack 8
Total Snack Sodium
Total Snack Sugar
Water (Cups)
Tabaco
Please Select
Yes
No
(Second-hand Smoke)
Caffeine
Please Select
Yes
No
Alcohol
Please Select
Yes
No
Medications/Supplements
List all
List all
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Excercise
Duration
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Type
Please Select
Cardio
Strength
Both
Notes
Stress
Stress Level
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Notes
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Vertigo Attacks
Have an attack?
Yes
No
How long?
Minutes
Notes
Daily Check-in
Morning
Afternoon
Night
Vertigo (1-10)
Dizziness (1-10)
Tinnitus (1-10)
Aural Fullness (1-10)
Brain Fog (1-10)
Headache (1-10)
Hearing Loss (1-10)
Nausea (1-10)
Sensory Overload (1-10)
Summary and Notes
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Clear Form
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