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WellnessPlus Food Journal
Home
WellnessPlus Food Journal
WellnessPlus Food Journal
wpengine
2024-04-02T22:45:54+00:00
"
*
" indicates required fields
Hidden
Date
*
DD slash MM slash YYYY
Section 1: Personal Information
Patient Name
*
First Name
Last Name
Date of Birth
*
DD slash MM slash YYYY
Phone
*
Email
*
Weight
*
Unit of measurement for weight
*
lbs
kg
Height
*
Unit of measurement for weight
*
Centimeters
Inches
Are you discomfort with your body size?
Yes
No
Do you currently consume alcohol?
*
Yes
No
If yes, do you have concerns with consuming alcohol?
Do you currently consume caffeinated products?
*
Yes
No
How much caffeine do you consume per day?
*
Section 2: Nutrition
Check off previous/ current behavior(s) [Check off all that apply]
*
None
Diet Pills/ supplements/ injections
Binge eating
Fluid restriction
Fat Restriction
Calorie Restriction
Other not listed
Other eating behavior(s) not mentioned above
Check off food craving(s) [Check off all that apply]
*
None
Sweet
Chocolate
Bread/ Pasta
Fried Food
Alcoholic Drinks
Meat
Soda
Other not listed
Other food cravings not mentioned above
Any food dislikes? [List below]
Add
Remove
Additional information
Section 3: 3-Day Food and Activity Journal
Please enter 3 days of your food. One day of the Journal should be more of a "free day" where you are more lenient in your diet.
Day 1
Date of day 1
*
MM slash DD slash YYYY
Time of Breakfast
Hours
:
Minutes
AM
PM
AM/PM
Breakfast Image (first meal of the day)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Time of Snack (1)
Hours
:
Minutes
AM
PM
AM/PM
Snack (1) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Time of Lunch
Hours
:
Minutes
AM
PM
AM/PM
Lunch Image (second meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Time of Snack (2)
Hours
:
Minutes
AM
PM
AM/PM
Snack (2) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Time of Dinner
Hours
:
Minutes
AM
PM
AM/PM
Dinner Image (third meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Time of Snack (3)
Hours
:
Minutes
AM
PM
AM/PM
Snack (3) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Day 2
Date of day 2
*
MM slash DD slash YYYY
Breakfast Image (first meal of the day)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (1) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Lunch Image (second meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (2) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Dinner Image (third meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (3) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Day 3
Date of day 3
*
MM slash DD slash YYYY
Breakfast Image (first meal of the day)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (1) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Lunch Image (second meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (2) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Dinner Image (third meal)
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Snack (3) Image
It will be helpful if you put something next to your food to show perspective of portion (ie: a pop can). If you do not eat this meal, just leave it blank
Max. file size: 1 GB.
Email
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