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)