Nutrition & Eating Online Record
A copy of this submission will be sent to me (Neshama) and a copy will be sent to you as well to keep for tracking purposes.
Name
*
First Name
Last Name
E-mail
*
Date of entry:
Day of the week of entry:
Time eaten:
Food and/or beverages eaten:
Food eaten was at:
Where did you eat this?
Activities while eating:
On a scale of 1-5, how HUNGRY were you before eating this food?
1
2
3
4
5
Not hungry at all
Ravenous
1 is Not hungry at all, 5 is Ravenous
Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
1
2
3
4
5
Any additional thoughts about how much and why you did or did not ENJOY this food?
How STRESSED were you when you ate this?
1
2
3
4
5
Least Stressed
Most Stressed
1 is Least Stressed, 5 is Most Stressed
Any additional thoughts about your STRESS while eating this?
Did you have any digestive issues after eating? If so, explain here:
Any final thoughts or "aha" moments?
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