http://www.bgsu.edu/departments/psych/health/page68282.html

Food and Exercise Diary abbreviated (2014)

1. Copy of page: Self-Monitoring Form

Question Title

* 1. Name and/or ID #:

Question Title

* 2. Date of Entry:

	Day of Week	Month	Day	Year
I	I Day of Week menu	I Month menu	I Day menu	I Year menu

Daily Calories Consumed

Question Title

* 3. Total Daily Caloric Intake (sum of food and beverage calories)

Daily Physical Activity

Question Title

* 4. Duration and Type of Physical Activity

If you did not exercise today, please type a zero for both Type and Duration.

If you did more than one activity, then indicate as:
Example: Duration (minutes): 40, 20, 10
Example: Type: Walk, lift weights, stretch

Duration (in minutes)

Type

Information from Accelerometer

Question Title

* 5. TOTAL CALS USED (for day)

Question Title

* 6. CALS USED/ACTM (for day)