DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ
DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ
DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ
DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ
DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ
DAILY FOOD DIARY
Weight
Fatigue
Yes
BREAKFAST
No
Shortness of
Breath
Yes
No
SODIUM MG
FLUID OZ
# of Pillows
BP
HR
BS
Out Put
Exercise / Other Activity
 Increased
 Decreased
 Same
LUNCH
SODIUM MG
FLUID OZ
Yes
DINNER
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met  Yes  No
2,000 mg per 24 hour sodium restriction met
 Yes  No
Other:___________________________________________________  Yes  No
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
No
SODIUM MG
FLUID OZ