Please fill out your 5-day diet record on the table below

Please write out a Typical daily diet and activity - relaxation schedule. Please include the amount of food and activity.

Note: It is helpful to describe both a good and bad day's eating and activities.

Day ___ of 5

Breakfast

Supplements/Medicines/Non-food toxins Activity

 

 

Lunch

 

 

Snack

 

 

Dinner

 

 

Nighttime Eating    

 

 

How much and what kind of beverages do you drink each day?
Water _____ Bottled juice _____ Milk _____
Coffee _____ Fresh juice _____ Alcohol _____
Herb tea _____ Soft drinks _____ Other _____