Food Mood Record

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The food mood record helps track you daily diet and symptoms that you feel throughout the day.....

1. Please write out your daily diet. Fill out a diet record for at least 10 to 14 days. Include portion size and any supplements or medications. Include time of day.

2. Additionally, record any symptoms you feel during or after eating, such as drowsy, irritable, energized, and others.

Name:____________________________ Height:________________ Weight:________________

Address:__________________________ DOB: _________________ Age: ____________

__________________________ Blood Type: ____________________

Home Ph: ________________________ Referred By: ____________________

Work Ph: ___________________________

Cell Ph: ____________________________

Email: _____________________________

Time Food/Supplements Mood/Energy/Symptoms

Example 9:00 1 cup of Cheerios with 3/4 cup of cow mile 10:00 Feel fine
1 multi-vit/min, 500 mg vit C 11:00 Low energy, stressed

Breakfast

Snack

Lunch

Snack

Dinner

Night-Time Eating

How much and what type of beverages do you drink each day:

Water ____ Fruit juices (type) _____________ Juice “drinks” ____________

Milk ____ Soft drinks (sugar or diet) ___________ Other ___________________

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