Well of Life Center for Holistic Healthcare

Daily Record of Food Intake Form

Each day, record all the items you eat and drink. Be sure to include the approximate amount of each item. When you have completed this form, return it to your health care professional for evaluation.

DAY 1

Selected Value: 1
1 - poor, 5 - good

DAY 2

Selected Value:
1 - poor, 5 - good

DAY 3

Selected Value:
1 - poor, 5 - good

DAY 4

Selected Value:
1 - poor, 5 - good

DAY 5

Selected Value:
1 - poor, 5 - good

DAY 6

Selected Value:
1 - poor, 5 - good

DAY 7

Selected Value:
1 - poor, 5 - good

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