This document is a record of your food and fluid intake, gastrointestinal function, medication, supplements, daily activity, physical repair, and emotional observations from your daily adventures. This information will help you and I develop a nutritional intervention to support the complete restoration of your best self. Thank you for choosing to participate in your healing!

  • NUTRITIONAL INTAKE

    Be as specific as you feel is necessary to reflect a vision of your daily intake. Please include ALL fluids, including water, and any added sweeteners.

  • DIGESTIVE HEALTH

  • Please note any bowel movement(s), symptoms of diarrhea or constipation, digestive stimulants (e.g., laxatives, edemas or suppositories) or any change in appearance/odor

  • MEDICATION/SUPPLEMENTS

  • ACTIVITY

    There difference between these two things are related to your mindset. Daily movement may include jogging two blocks to catch the bus or meet a loved one you haven't seen in a long timer. Intentional exercise distinguishes an action or group of activities that were initiated for a specific purpose (e.g., 30 minutes of weight training (lower body) or 60 minutes of yoga for flexibility)

  • PHYSICAL REPAIR

    Your body actively uses sleep as the time to repair and create new cells and assess areas needing improvement.
  • Previous day
  • Today
  • For example, if you went to bed at 11:00 pm (last night) and woke up at 7:30 am (today). You would enter in 8.5
  • Scale (1-10), how restful did you feel upon waking? A rank of 10 indicates feeling like you can take on the world.

  • EMOTIONAL HEALTH

  • Rank your mood 1-10 (poor to excellent)
  • Rank your energy 1-10 (poor to excellent)
  • Rank your perceived stress 1-10 (low to high)
  • List any events, people, or experiences that contributed to changes in your mood, energy, or perceived stress levels today

  • SUMMARY

  • SUPPORTING FILES OR PHOTOS


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