Food, Liquid & Activity Form
Guidelines:
Please complete this form for three days to provide a general overview of your nutritional intake on a typical day, submitting once for each day. The purpose of this record is NOT to judge your eating habits but to learn more about your nutritional and biochemical needs and strengths. Write down EVERYTHING you eat for meals and snacks (be sure to include amounts (i.e. cup, tablespoon, or portion size). List BRAND NAMES of foods you bought in a supermarket. List EXACT INGREDIENTS of homemade foods. The scale of 1 to 5 indicates 1 being “the least” and 5 being “the most”.
Date
First Name
Last Name
Time of Morning Meal
Morning Meal
Hunger Level Before Morning Meal
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Morning Meal
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Morning Meal
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Morning Meal
1 - Least, 5 - Most
1
2
3
4
5
Time of Snack
Snack
Hunger Level Before Snack
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Snack
1 - Least, 5 - Most
1
2
3
4
5
Time of Mid-Day Meal
Mid-Day Meal
Hunger Level Before Mid-Day Meal
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Mid-Day Meal
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Mid-Day Meal
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Mid-Day Meal
1 - Least, 5 - Most
1
2
3
4
5
Time of Snack
Snack
Hunger Level Before Snack
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Snack
1 - Least, 5 - Most
1
2
3
4
5
Time of Evening Meal
Evening Meal
Hunger Level Before Evening Meal
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Evening Meal
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Evening Meal
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Evening Meal
1 - Least, 5 - Most
1
2
3
4
5
Time of Snack
Snack
Hunger Level Before Snack
1 - Least, 5 - Most
1
2
3
4
5
Satisfaction Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Energy Level Level After Snack
1 - Least, 5 - Most
1
2
3
4
5
Nourishment Level of Snack
1 - Least, 5 - Most
1
2
3
4
5
Water/Drinks
Physical Activity / Exercise (Type)
Duration of Exercise
Relaxation (Type)
Duration of Relaxation
Sleep: Bed Time of Previous Night
Sleep: Wake Up Time
Sleep: Number of times you wake up at night
Reason for waking during the night
Nutritional Supplements and Medications Taken (Dose & Frequency)
Bowel Movements: Include time of each BM and if it was formed (F), diarrhea (D), or constipation (C)
Health Symptoms
Check all that apply:
Typical Day
Work Day
Day Off
Unusual Day
Additional Comments
Submit
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