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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
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WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
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ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Diet Activity Report

DATE:
Name:
E-Mail:

WSN Acct. No.:

Please take the time to complete the following survey carefully and accurately. List in detail the quantity and the exact nature of all foods and beverages consumed (i.e. frozen, canned, etc.). Please mention if the foods were raw, steamed, cooked, etc. Be sure to list all beverages, all fats or oils and any condiments used and their brand names (i.e., Health Valley Mayonnaise, Dejon Mustard, spices, herbs, sweeteners, etc.).

Please complete the exercise activity portion at the bottom as well, listing the type of exercise, its duration and your pulse before and during exercising, unless completing the Exercise and Athletic Training Questionnaire.

Record type of relaxation and duration. Watching Television is not considered a relaxation activity.

The word "State" above "Time" refers to your state of emotions when eating. Put 0 for being totally relaxed when eating to 10 being rushed and/or stressed.

************Day 1************
ACTIVITY Day 1
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 2************
ACTIVITY Day 2
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 3************
ACTIVITY Day 3
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 4************
ACTIVITY Day 4
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 5************
ACTIVITY Day 5
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 6************
ACTIVITY Day 6
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

************Day 7************
ACTIVITY Day 7
Date: Week:
Morning Meal
State:
Time:
Snack
State:
Time:
Noon Meal
State:
Time:
Snack
State:
Time:
Evening Meal
State:
Time:
Snack
State:
Time:
Water (Ounces Per Day)
Additional Beverages
Fats/Oils
Condiments
Exercise Type:
Duration
Pulse Before:
Pulse During:
Relaxation Type:
Duration

Copyright, 1994 Health Coach Systems International, Inc.