Food Journal Review Intake Form

Welcome to Your Food Journal Intake Form

STEP 1: Click to Reserve Your Appointment

Reserve 1 week from now and it will keep you accountable to do the work before our appointment.

Step 2:

Record everything that you eat (and drink) for 4 days. Ideally, that would be 3 Weekdays + 1 Weekend Day

Fill out the form below from your tracking app or sheet

You have a few options for tracking your food:

1. You may write everything that you ate, and add approximate portion size and time. Please list them by meal number, and start a new line for each new time of feeding.

2. Alternately, you may upload photos of what you eat. Please still indicate which pic is while meal number. Also, give me a plate size indication OR some relative scale visual (like a fork next to a plate) so I can better assess how much food is represented. I like the App for iOS called YouAte. It tracks images and also how you felt about eating.

(If there is food that is not obvious (like a liquid, sauce or oil) on a food, just make a note with serving approximations on it as well.)

Helpful Apps

YouAte
MyFitnessPal
Cronomete

Next Step: Fill Out the Form (All fields are Required)

Name *

Email *

Date *

Height *

Weight *

Waist Measurement (at Belly Button level) *

Estimated Body Fat % *

Age *

What is your #1 Goal (Be Specific) *

Let me know what the number one thing you want to improve about your healthy, performance or body composition. (ie. Lose 5% body fat, Run a 5K faster, Get ready for a photo session etc.)

What is Your Time Frame for Accomplishing This? *

You can use either one definitive time frame or a realistic, specific time range.

Which "Way of Eating" (WOE) do you prefer to use? *

Please record everything you eat and drink for 3 days. Be as thorough and detailed as possible. Please be as honest as you can be. I am gathering data, not judging. Don’t change your normal routine. Just record what you are doing. If your eating habits change over the week, pick 3 days that are representative (e.g., 2 weekdays plus 1 weekend day). To measure, simply use hand-sized portions (e.g., 1 palm, 1 fist, 1 cupped handful, 1 thumb) or something else standardized (e.g., baseball, deck of cards). You can use measuring cups or a food scale if you want, but you don’t have to. Record any other notes about other things we’ve agreed you’ll record, such as why you are eating, physical sensations from eating, how you felt after you ate. *

Example: 7 AM - 2pcs whole grain toast, 2 thumbs peanuts butter, 1 mug of coffee with milk+2 sugars NOTES: Rushing out the door; busy day 10: 15 AM - Bran muffin (about 1 fist sized), 1 medium-sized orange, medium coffee from Dunkin Donuts NOTES: In a meeting 12:30 PM - 12" Subway turkey sandwich, 1 can Diet Coke NOTES: No cheese 3:30 PM - 1 strawberry Greek yogurt, 2 handful Triscuits NOTES: Ate at desk 6;30 PM - 3 slices Meatlovers Pizza, 2 light beers, 1 bowl moose tracks ice cream NOTES: Got home late; no energy to cook

Day 1

Upload Meal Images Here (Optional)

Use the description field to give plate sizes, and any other details (meal time, how you were feeling, life situations)

Day 2

Upload Meal Images Here (Optional)

Use the description field to give plate sizes, and any other details (meal time, how you were feeling, life situations)

Day 3

Upload Meal Image Here (Optional)

Use the description field to give plate sizes, and any other details (meal time, how you were feeling, life situations)

Any extraordinary circumstances or additional information for me?

Feel free to include anything you think is important for me to know about issues or challenges related to achieving your goals. Watch your email for a personalized video report with my recommendations for you. Please allow 3 Days for the report to arrive. Be sure and whitelist anne@anneberryhill.com and ketofitcoach@gmail.com in your email program so the report can reach your inbox!

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