Quality of Life Assistant
Food and Beverage Chart
Please use this chart to help determine patterns to your food triggers. Blanks have been left for you to individualize the chart to your needs. Check food labels for sodium content, etc. This chart is intended to be utilized as an adjunct to a food journal.
| Category | Item (Specify) |
Amount (Specify) |
Time (Specify) |
Portion (Specify) |
Effects (Specify) |
|---|---|---|---|---|---|
| Fruit | |||||
| Vegetable | |||||
| Legume (lentils, etc) |
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| Meats | |||||
| Fish | |||||
| Poultry | |||||
| Potato | |||||
| bread | |||||
| Pasta Rice | |||||
| Dairy (Milk, cheese,etc.) |
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| Nuts | |||||
| Beverage | |||||
| Alcohol | |||||
| Fast Food ( Pizza, etc) |
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| Processed Foods (cookies, cake, etc.) |
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| Sodium Level | |||||
| Potassium Level | |||||
| Sugar Level | |||||
| Candy | |||||