Patient Name
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Date
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Please list any known food allergies and food cravings
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Do you avoid the following foods and drinks?
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Special Diet
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Supplements
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Day 1 (List Foods & Liquids Consumed)

Day 1 Breakfast
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How did I feel after the meal?
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Day 1 Lunch
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How did I feel after the meal?
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Day 1 Dinner
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How did I feel after the meal?
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Day 1 Snacks
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How did I feel after the snack?
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Day 1 Beverages
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How did I feel after the beverage(s)?
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Day 2 (List Foods & Liquids Consumed)

Day 2 Breakfast
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How did I feel after the meal?
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Day 2 Lunch
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How did I feel after the meal?
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Day 2 Dinner
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How did I feel after the meal?
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Day 2 Snacks
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How did I feel after the snack?
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Day 2 Beverages
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How did I feel after the beverage(s)?
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Day 3 (List Foods & Liquids Consumed)

Day 3 Breakfast
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How did I feel after the meal?
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Day 3 Lunch
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How did I feel after the meal?
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Day 3 Dinner
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How did I feel after the meal?
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Day 3 Snacks
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How did I feel after the snack?
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Day 3 Beverages
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How did I feel after the beverage(s)?
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Day 4 (List Foods & Liquids Consumed)

Day 4 Breakfast
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How did I feel after the meal?
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Day 4 Lunch
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How did I feel after the meal?
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Day 4 Dinner
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How did I feel after the meal?
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Day 4 Snacks
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How did I feel after the snack?
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Day 4 Beverages
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How did I feel after the beverage(s)?
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Day 5 (List Foods & Liquids Consumed)

Day 5 Breakfast
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How did I feel after the meal?
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Day 5 Lunch
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How did I feel after the meal?
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Day 5 Dinner
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How did I feel after the meal?
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Day 5 Snacks
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How did I feel after the snack?
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Day 5 Beverages
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How did I feel after the beverage(s)?
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Day 6 (List Foods & Liquids Consumed)

Day 6 Breakfast
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How did I feel after the meal?
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Day 6 Lunch
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How did I feel after the meal?
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Day 6 Dinner
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How did I feel after the meal?
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Day 6 Snacks
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How did I feel after the snack?
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Day 6 Beverages
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How did I feel after the beverage(s)?
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Day 7 (List Foods & Liquids Consumed)

Day 7 Breakfast
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How did I feel after the meal?
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Day 7 Lunch
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How did I feel after the meal?
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Day 7 Dinner
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How did I feel after the meal?
Invalid Input

Day 7 Snacks
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How did I feel after the snack?
Invalid Input

Day 7 Beverages
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How did I feel after the beverage(s)?
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