4) In each of the areas listed below (as applicable) please indicate if it was easy or challenging to follow the recommendations provided during our last visit. Use a scale of 1-10, with one being the easiest and ten being the hardest.
3-Day Food Diary and Instructions
It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.
Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
Record information as soon as possible after the food has been consumed
Describe the food or beverage as accurately as possible e.g., milk - what kind? (whole, 2%, nonfat); toast (whole wheat, white, buttered); chicken (fried, baked, breaded); coffee (decaffeinated with sugar and 1/2 & 1/2).
Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc.)
Please note all bowel movements and their consistency (regular, loose, firm, etc.)
The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health for the past 30 days. If you are taking this for a repeat visit, record your symptoms for the past 48 hours ONLY.
0 = Never or almost never have these symptoms
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
(not near or farsightedness)
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