Daily Food & Mood Journal
Record
 
First and Last Name: *

 
Journal Entry Date: *

 
Sleep

 
What time did you go to bed?

 
What time did you wake up?

 
How well did you sleep and did you wake during the night?

 
How did you feel upon awakening?

 
Breakfast

 
What time did you eat breakfast?

 
What did you eat and drink for breakfast?

Please include approximate serving sizes
 
Where did you eat your first meal?

Ex. Home, Restaurant, Work, Car, etc.
 
Describe any digestive problems you experienced during or after breakfast:

 
Describe any changes in mood or energy you experienced before or after breakfast:

 
Lunch

 
What time did you eat lunch?

 
What did you eat and drink for lunch?

Please include approximate serving sizes.
 
Where did you eat lunch?

Ex. Home, Restaurant, Work, Car, etc.
 
Describe any digestive problems you experienced during or after lunch:

 
Describe any changes in mood or energy you experienced before or after lunch:

 
Dinner

 
What time did you eat dinner?

 
What did you eat and drink for dinner?

Please list approximate serving sizes.
 
Where did you eat dinner?

Ex. Home, Restaurant, Work, Car, etc.
 
Describe and digestive problems you experience during or after dinner:

 
Describe any changes in mood or energy you experienced before or after dinner:

 
Snacks & Beverages

 
Please list any additional snacks and beverages you had today and when you had them:

 
How many 16 oz. servings of water did you have today?

1 bottle = 16 oz = 2 cups
 
Activity & Mood

 
What type of physical activity did you engage in today?

List type, duration and time of day.
 
How did you feel after the physical activity?

Ex: Energized, Tired, Focused, Lethargic, Sore, ect.
 
How would you rate your overall energy level today?

 
How would you rate your overall mood today?

1 - Depressed
2 - Anxious
3 - Content
4 - Peaceful
5 - Happy





 
Elimination

 
How many bowel movements did you have today?

 
Select the answers that best describe your stools?


 
Additional thoughts about today:

 
You have the option to upload a Food Journal document below.

Thank you for submitting your entry today.
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