Diet Check Record
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Breakfast time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
List breakfast food items (do not count or weigh)
1-2 hours after breakfast (check all that apply)
Feel full and satisfied
Feel full, but still hungry
DO NOT have sweet cravings
Have sweet craving
DO NOT desire more food
Not satisfied, something was missing
DO NOT feel hungry
Already hungry
DO NOT need to snack before meal
Need a snack before the next meal
Energy feels renewed
Meal gave too much or too little energy
Have a good lasting sense of energy
Became hyper,jittery, shaky, nervous or speedy
Improved well-being
Energy tanked - exhausted, sleepy, drowsy, listless, or lethargic
Feel refueled, renewed, restored
Mentally slow, sluggish, or spacy
Some emotional upliftment
Inability to think quickly or clearly
Improved mental clarity and sharpness
Hyper, overly rapid thoughts
Apathy, depression, withdrawal, or sadness
Inability to focus or concentrate
Anxious, obsessive, fearful, angry, or irritable
Normalization of thought processes
Lunch time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
List lunch food itmes (do not count or weigh)
1-2 hours after lunch (check all that apply)
Feel full and satisfied
Feel full, but still hungry
DO NOT have sweet cravings
Have sweet craving
DO NOT desire more food
Not satisfied, something was missing
DO NOT feel hungry
Already hungry
DO NOT need to snack before meal
Need a snack before the next meal
Energy feels renewed
Meal gave too much or too little energy
Have a good lasting sense of energy
Became hyper,jittery, shaky, nervous or speedy
Improved well-being
Energy tanked - exhausted, sleepy, drowsy, listless, or lethargic
Feel refueled, renewed, restored
Mentally slow, sluggish, or spacy
Some emotional upliftment
Inability to think quickly or clearly
Improved mental clarity and sharpness
Hyper, overly rapid thoughts
Apathy, depression, withdrawal, or sadness
Inability to focus or concentrate
Anxious, obsessive, fearful, angry, or irritable
Normalization of thought processes
Dinner time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
List dinner food items (do not count or weigh)
1-2 hours after dinner (check all that apply)
Feel full and satisfied
Feel full, but still hungry
DO NOT have sweet cravings
Have sweet craving
DO NOT desire more food
Not satisfied, something was missing
DO NOT feel hungry
Already hungry
DO NOT need to snack before meal
Need a snack before the next meal
Energy feels renewed
Meal gave too much or too little energy
Have a good lasting sense of energy
Became hyper,jittery, shaky, nervous or speedy
Improved well-being
Energy tanked - exhausted, sleepy, drowsy, listless, or lethargic
Feel refueled, renewed, restored
Mentally slow, sluggish, or spacy
Some emotional upliftment
Inability to think quickly or clearly
Improved mental clarity and sharpness
Hyper, overly rapid thoughts
Apathy, depression, withdrawal, or sadness
Inability to focus or concentrate
Anxious, obsessive, fearful, angry, or irritable
Normalization of thought processes
List snacks between dinner and bedtime
Describe how you felt overall today
How many glasses of water did you drink today
How many bowel movements did you have today
Submit
Should be Empty: