Diet, Nutrition, and Lifestyle Journal – 1 Day Patient Name________________________________________________________________ Date____________________ Food Plan Type:______________________________________________________________________________________
Day 1 Day Event
Food & Drink Intake
(include type, amount, brand)
Macronutrients (PFC) and Phytonutrients
Rising Time _________________ P__________________F_________________ C
Breakfast Time
o R
o O o Y
o G
o B/P/BL
o W/T/BR
Mid-AM Snack Time
_________________ P__________________F_________________ C
Lunch Time
_________________ P__________________F_________________ C
Mid-PM Snack Time
_________________ P__________________F_________________ C
Dinner Time
_________________ P__________________F_________________ C
PM Snack Time
_________________ P__________________F_________________ C
o R
o R
o R
o R
o R
o O o Y
o O o Y
o O o Y
o O o Y
o O o Y
o G
o G
o G
o G
o G
o B/P/BL
o B/P/BL
o B/P/BL
o B/P/BL
o B/P/BL
o W/T/BR
o W/T/BR
o W/T/BR
o W/T/BR
o W/T/BR
Bed Time P: Proteins; F: Fats; C: Carbohydrates; R: Red; O: Orange; Y: Yellow; G: Green; B/P/BL: Blue/Purple/Black; W/T/BR: White/Tan/Brown
Sleep & Relaxation
Exercise & Movement
Stress
Relationships
Sleep Quantity: ______ (hours) Quality: o Poor o Fair o Good
Type, Duration, & Intensity
Stress Reduction Practices:
Supporting:
Stressors:
Non-supporting:
Relaxation o Yes o No Type/Amount:
Mental
Version 2
o Aerobic:
o Strength:
o Flexibility:
Emotional
Spiritual
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