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6. .. Approved F6ARG@WAXe AXBROIGE CINFURRESEATNG8R001700210023-7 (SUGGESTED FORM FOR PERSONAL RECORD) Name Date Time of Day am,pm Location Body Position: Lying on back,side, prone, sitting. Body Temperature: Cold, Warm,Hot Mood Energy Level Previous Exercise: Date Time OPTIONAL INFORMATION INTERNAL STATE 10, ti. 15. Time since last meal _ hrs. Physical distrubances (e.g. headache) Special Diet Medicines Psychotropic Drugs General Health Level: EXTERNAL STATE 16. Clothing: Full, light, none Head pointed or body facing what direction: N,NE, E,SE,S,SW,W,NW. Exterior Aids (e.g. Pyramid power) Room Temperature LT Phase of Moon Outside Weather Distracting Facto Approved For Release 2003/09/46 GAME PLAN: My proposed objectives and methods-- A specific Plan of the Exercise: ACTUAL EVENTS OF THE EXERCISE: The tools I used, if any; how well I completed by objectives, and any subsequent and unforseen developments during the Exercise: (Continued on reverse side) 23. Mood or Energy Level changed? 24, General Comment