Nutrition & Eating Online Record

Full Day: Nutrition & Eating Online Record
A copy of this submission will be sent to me (Neshama) and a copy will be sent to you as well to keep for tracking purposes. Feel free to skip any sections that are not relevant to you today.
Name*

First NameLast Name
E-mail*
Date of entry:
Day of the week of entry:
Sleep
Last night I fell asleep at:
Today I woke up at __ time:
I slept for __ # of total hours:
I would describe last night's sleep as:
First Food Entry of the Day
Time eaten:
Food and/or beverages eaten:
Food eaten was at:
Where did you eat this?
Activities while eating:

On a scale of 1-5, how HUNGRY were you before eating this food?

	1	2	3	4	5

1 is Not hungry at all, 5 is Ravenous

Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
Any additional thoughts about how much and why you did or did not ENJOY this food?

How STRESSED were you when you ate this?

	1	2	3	4	5

1 is Least Stressed, 5 is Most Stressed

On a scale of 1-5, how HUNGRY were you before eating this food?

	1	2	3	4	5

1 is Not hungry at all, 5 is Ravenous

Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
Any additional thoughts about how much and why you did or did not ENJOY this food?

How STRESSED were you when you ate this?

	1	2	3	4	5

1 is Least Stressed, 5 is Most Stressed

On a scale of 1-5, how HUNGRY were you before eating this food?

	1	2	3	4	5

1 is Not hungry at all, 5 is Ravenous

Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
Any additional thoughts about how much and why you did or did not ENJOY this food?

How STRESSED were you when you ate this?

	1	2	3	4	5

1 is Least Stressed, 5 is Most Stressed

On a scale of 1-5, how HUNGRY were you before eating this food?

	1	2	3	4	5

1 is Not hungry at all, 5 is Ravenous

Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
Any additional thoughts about how much and why you did or did not ENJOY this food?

How STRESSED were you when you ate this?

	1	2	3	4	5

1 is Least Stressed, 5 is Most Stressed

On a scale of 1-5, how HUNGRY were you before eating this food?

	1	2	3	4	5

1 is Not hungry at all, 5 is Ravenous

Any additional thoughts about how HUNGRY you were:
On a scale of 1-5 stars, how much did you ENJOY this food? (1= not at all; 5= enjoyed immensely)
Any additional thoughts about how much and why you did or did not ENJOY this food?

How STRESSED were you when you ate this?

	1	2	3	4	5

1 is Least Stressed, 5 is Most Stressed

Full Day: Nutrition & Eating Online Record