• Please feel free to enter information directly on this form. Alternatively, if you prefer you can print out, fill out, scan, and send back to me via email.

    • If you are filling out this form for your initial assessment, please keep in mind that this is an evaluation of your current eating habits and will be helpful in assessing your current diet and routine. With that in mind, please provide at least 2 days of all that you ate and eat as you normally do!
    • Please include method of preparation such as grilled, deep fried, baked, etc.
    • In the third column please note any feelings that you had before, during, or after consumption, if you were eating due to a situation other than hunger (such as boredom). Also, note if you didn’t feel well after food consumption, any activity that you had during the day such as exercise, and your quality of sleep.

  • Date/TimeItem Consumed (Food, Beverage, Supplement, Medication)Comment / Symptom / Activity 
    Click "+" next to the row to add additional items
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