1. Copy of page: Self-Monitoring Form

1. Name and/or ID #:

Daily Calories Consumed

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

Daily Physical Activity

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

Information from Accelerometer

5. TOTAL CALS USED (for day)

6. CALS USED/ACTM (for day)