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


Supplements/Medicines/Non-food toxins Activity












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 _____