Diet Check Record
Fill out form for each meal eaten about 1-2HRS AFTER eating, to see how the meal made you feel. Please remember to photograph you meal if possible to show better proportion sizes. The + signs indicate a Good Reaction, a - sign indicates a Bad Reaction. This is important to start to associate with certain foods and food combinations.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
MEAL TYPE & TIME EATEN (ie. Breakfast 8:30am)
Take a photo of your meal
If not photo upload, please enter meal description here:
1-2 HOURS AFTER EATING, please answer the following:
Rate you stress level while eating:
1
2
3
4
5
No stress/Calm
High stress/Rapid heart rate
1 is No stress/Calm, 5 is High stress/Rapid heart rate
APPETITE/SATIETY
YES
NO
+ Feel full, satisfied
+ Do NOT have sweet cravings
+ Do NOT desire more food
+ Do NOT feel hungry
+ Do NOT need snack before next meal
- Feel physically full, but still hungry
-
Have desire for something sweet
-
Not satisfied, feel like something was missing
-
Already hungry
-
Feel the need for a snack
ENERGY LEVELS
YES
NO
+ Energy feels renewed
+ Have good, lasting, "normal" sense of energy
- Meal gave too much or too little energy
- Became hyper, jittery, shaky, nervous or speedy
- Felt hyper, but exhausted "underneath"
- Energy tanked from meal- exhaustion, sleepy
MIND, EMOTIONS, & WELL-BEING
YES
NO
+ Improved well-being
+ Sense of feeling refused, renewed and restored
+ Some emotional upliftment
+ Improved mental clarity
+ Normalization of thought process
- Mental slow, sluggish, or spacey
- Inability to think quickly, or clearly
- Hyper, overly rapid thoughts
- Inability to focus or concentrate
- Apathy, depression, withdraw or sadness
- Anxious, obsessive, fearful, angry, or irritable
CHECK IF YOU EXPERIENCE ANY OF THE FOLLOWING DISCOMFORT/SYMPTOMS:
Digestion/bowl discomfort
Joint/muscle aches
Nasal or chest congestion
Headache/pressure
Please add additional comments here:
Submit
Should be Empty: