Name: Gastrointestinal Food and Symptom Diary

Please see final page if just needing to record a ‘typical day’. This is often used when there is a short time between booking an appointment and seeing the dietitian.

Please record all food and drinks, including tea, coffee and supplements.

Rate the severity of your symptoms by circling the relevant number, with 0=none at all to 5=severe

EXAMPLE

Day	Time: 7.15	Time: 8 am	Time: 1.45pm	Time: 4.45pm	Time: 8pm	Time: 9pm
Monday	2 Weet bix with full cream milk Tea - white, 1 sugar	Nil Water	Toasted cheese and ham sandwich – grain bread Yoghurt - fruit	Nuts Water	Lasagne with salad – lettuce, tomato, cucumber, avocado	Fruit salad
Symptoms/ Stool form:	Cramps	Bloating + cramps	Diarrhoea	Bloating
Other info:	Went for a run	Very tired	Headache
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 1

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 2

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 3

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 4

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 5

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 6

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Day 7

Day	Time:	Time:	Time:	Time:	Time:	Time:
Symptoms/ Stool form:
Other info:
Severity Score:	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5	0 1 2 3 4 5

Typical Day

Please describe a typical day of food intake. Include different types of meals and snacks that you may eat and drink.

Time	Usual options	Comments/ Symptoms/ Stool form: Severity score
Breakfast
Snack
Lunch
Snack
Evening meal
Snack
Drinks

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