Daily Record Of Food Intake

During the initial weeks of your nutritional program we want to discover your usual consumption and eliminative patterns. Please do not change anything in your diet during this initial phase. Eat with gusto all the food and beverages you normally consume.

Keep the Daily Record of Food Intake form with you each day and write down what you are consuming as you consume it. This goes for beverages as well. For now we simply want to get a snapshot of your dietary intake. Be sure to track bowel movements by frequency, color and texture if not like thick brown toothpaste. Please track your sleep. Circle the quality, good or if there was a diminished quality in sleep such as delayed sleep(taking longer than 20-30 minutes to fall asleep) or if there are difficulties staying asleep. Track any exercise both formal such as weight training, cross fit, walking or what is termed NEA which means non-exercise activity such as walking up steps, vacuuming, shoveling dirt. An alternative form can be requested by calling 510.795.2700.

DAILY RECORD FOOD INTAKE

DAY 1

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 2

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 3

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 4

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 5

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 6

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

DAY 7

Breakfast:_________________________________________________________

Mid-Morning Snack:_________________________________________________

Lunch:____________________________________________________________

Mid-Day Snack:____________________________________________________

Dinner:___________________________________________________________

Night Time Snack:__________________________________________________

Beverages:________________________________________________________

Bowel Movements (How many, color and consistency):____________________

Hours of Sleep:____________  Quality:    GOOD      Difficulty    FALLING     STAYING     Asleep

Exercise (Type):___________________________________________________

Please turn in form after day seven for assessment // evaluation.