626.963.6627

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Free 30 min. Phone Consult
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(626) 963-6627

Directions:

Fill out this Food-Energy form and submit.

You may also use other templates such as www.myfitnesspal.com.

Your Name (required)

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Today's Date

List time and description of each Bowel Movement:

Breakfast Time

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

Snack Time morning

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

Lunch Time

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

Snack Time afternoon

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

Dinner Time

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

Snack Time evening

List Foods and Amount
List Liquids and Amount (how much water, tea, juice, soda)
List your Mood (how did you feel before and after you ate)

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