Morning (Time: 6:50-7:00 am )
Beverages: Milkshake
Portion 1 Glass
Calories: 130
Did you eat something today only because of habit?
Yes
Did you skip any meals today?
No
Did you go longer than four to five hours without? Food: __________________________ eating?
Portion:_________________________ Yes
Calories:________________________ Did you eat too little in the morning?
No
Food: ______________________ Did you eat more at night than any other time?
Portion:_________________________ No
Calories:________________________ Did you eat a lot of high-fat foods, such as whole
dairy, fried foods, or desserts?
Snacks (Time:__________ ) No
Food: __________________________ Did you eat the same food as you do every other
Portion:_________________________ day?
Calories:________________________ Yes
Did you eat according to your mood rather hunger
Food: __________________________ today?
Portion:_________________________ No
Calories:________________________
Beverages: ______________________
Portion:_________________________
Calories:________________________
1/22/13
Dinner (Time:6:00 pm )
Dinner (Time:6:00 pm )
Food: Vegetable soup
Portion: 1 serving
Calories: 200
Food: __________________________
Portion:_________________________
Calories:________________________
Portion: 1 serving
Calories: 200
Food: __________________________
Portion:_________________________
Calories:________________________
Beverages: Pineapple water
Portion: 1 glass
Calories 120