To use this diary:
1. Print out a copy of this form.
2. Make seven copies (one for each day).
3. Record everything you eat for a week.
4. Record your preferences, how you feel, etc.
5. Use your answers to become conscious of eating patterns and positive and negative reactions to foods.
6. Use the information when planning changes to your diet.
| Foods Consumed: | Bread / Cereal | Vegetable | Fruit | Milk | Meat / Protein | Added Sugar |
|---|---|---|---|---|---|---|
| Breakfast | ||||||
| Snack | ||||||
| Lunch | ||||||
| Snack | ||||||
| Dinner | ||||||
| Snack |
My reactions to food I ate: Check or list all that apply.
Foods that made me feel good:
- ___Kept me feeling full
- ___Left me generally satisfied
- ___Ended my cravings
- ___Tasted good
- ___Other:
Foods that made me feel bad :
- ___Left me hungry again right away
- ___Left me too full
- ___Didn’t digest well
- ___Gave me a headache
- ___Gave me gas, burping
- ___Gave me a skin rash
- ___Left me tired soon after eating
- ___Other:
Foods I enjoyed eating include:
Foods I didn’t like include:
Foods I craved include:
Check or list all that apply.
Times when I snacked:
How I felt when I wanted a snack:
- ___Hungry
- ___Restless
- ___Depressed
- ___Bored
- ___Other:
Types of snacks I generally chose:
Number of times I ate in a restaurant or fast food establishment:
Convenience foods I used:
Fresh foods I ate:
Times I overate or binged:
Number of times I skipped a meal:
Number of meals I prepared at home:
Obstacles to preparing meals at home this week:
What I can do to improve my diet:
Copyright 2007, Healthnotes, Inc., 1505 S.E. Gideon St., Suite 200, Portland, Oregon 97202, www.Healthnotes.com.
2006-09-07
