,t diary :~ : 1' .., ~. f name' mark ... file(oj.,~.~... .,:..".' "..,...:...

1
F :~ ....:_1' ... , ~. . . '~"" Da""~"""" .: . :. ", c .2 .•.. .IV (J o .,~ .~ .. , . . :. ." .' " .. , . . .: Mark(.) Ifyouengagedinbehavior. .•... Rate (0-5) I(youhadanurgebutdidnot' '.' . engageInbehavior.. ~.....:. .s' ss -1iJ "Co. ".- :;:s .a~ 1.1...' ;. Bradycardia Tachycardia Orthostasis. , Shame DIARY CARD .... ,t "'::....!~;... .'"I Living .••.. tu, f'ood~ i Name' - . I" UI~ I tl,Emotio n sl,Ratin 9 ' wI W /.c 'o :r: cnO>- '- ~ o '0 .' Today. .(0-5).. C •.• (fl. W i:il 6: ~ ~ Ci5 £ 0 '.. [Jl Pai~/Misery . Anxiety/Fear' .Sadn~ss T' .', -. ....J . i i .' . .' . . .. . :§ , ~ood Intake - Inclu~~ approximate quantity and descripUon of food' o.Hunger Scale - Grapn hunger level from start to end of rneal. '. ...•• «. I; .. .' '. •. Ii I '-':'1: :.; .:1.';'·,,' ...• '. TIME OF DAY z ::s Q. MEALS :;fli~1~:R,~tK~~~f:iM,;[\~" e~ 3 1/4 l~neutral'l ~ 6 1 7 r B~r 9]stulfed: Protein . HI ' T Vegetable . i I Gm~ I Lipid N. ./ Fruit Dairy :!r;~J::r:::·'t:,i:·SNACK!};:,:,;:J;;~I,i!;1 empty r :1 ~ . 31!l41 heutrall 6' T71' 8····-r9 .. 1", stuffed Protein .T Veaetable l' G~n I Lipid N. ,I Fruit Dairy ! I ., .;" !~ilj1~(:jL~~C~jl;ij::·iji(srrempty r2l3ln~,neut~ 617T 8 r 9 I stuffed Protein -:1; Vegetable I; . Grain l'. Lipid N. II i Fru~ : .' Dairy II I! fiii!;.4~~~~:24=:Lj..-""'';-':''~'''-...:.L_-il'----lL.:..--''''-...I.-'''''''';-L''''';'''...:.L_ .. _8.,-'' 1<9.,lstUff!ld '[ .", Anger· .. · '" .; I , ~ ::(:i:!:i;},:!'''i:;~SNA(l~n:,;!);~:ITf~mpty r~'''TYl1r4'l neutral] 6T, 7T'8 .. r·9 1 .stuffed . Protein ,. ;!. Vegetable ,;. Grain Ii Lipid N. . Ii Fruit Ii'. Dairy ,t . . :1;M:;i~:!1:i:y'"TA~"~~:;';%~tN I !iyes no I~ JIo' q .... ii"~ I ./ " Joy Urge to quit txlrecovery I Lying! . Withholding .1 Protocols Y. N·. Y'. N, Y N. '" ,,', ~~ ,,:. . :"~';.'

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Page 1: ,t DIARY :~ : 1' .., ~. F Name' Mark ... file(oJ.,~.~... .,:..".' "..,...: Mark(.) ... "Co. "..a~- :;:s 1.1 .'; Bradycardia Tachycardia Orthostasis. , Shame DIARY CARD....,t "'::

F:~ ....:_1' ... , ~.

. .'~""

Da""~"""".: . :.

",

c.2.•...IV(Jo

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.~ .. ,. .:. ." .' " .. ,. . .:

Mark(.) If you engagedin behavior. .•...Rate (0-5) I(you hadan urgebut did not' '.'

. engage Inbehavior..~.....:..s'ss-1iJ"Co.

".- :;:s.a~1.1...' ;.

BradycardiaTachycardiaOrthostasis. ,

Shame

DIARYCARD

....,t"'::.. ..!~;.... '" I

Living .••..tu, f'ood~·i Name'- . I" •

UI~ Itl,Emotionsl,Ratin9'wI W /.c 'o :r:cnO>- '-~ o '0 .' Today. . (0-5)..C •.• (fl. W

i:il 6: ~ ~ Ci5 £ 0 '...« [Jl

Pai~/Misery .

Anxiety/Fear'

.Sadn~ss

T' .', -.....J . i i .' . .' . . .. .:§ ,~ood Intake - Inclu~~ approximate quantity and descripUon of food'o .Hunger Scale - Grapn hunger level from start to end of rneal. '. . ..••« . I ; .. .' '. • .

Ii

I

'-':'1:

:.;

.:1.';'·,,' ...• '.

TIMEOFDAY

z::sQ. MEALS

:;fli~1~:R,~tK~~~f:iM,;[\~"e~ 3 1/4 l~neutral'l ~6 1 7 r B~r 9]stulfed:Protein .HI 'T

Vegetable . iIGm~ I

Lipid N. ./FruitDairy

:!r;~J::r:::·'t:,i:·SNACK!};:,:,;:J;;~I,i!;1 empty r :1 ~ .31!l41 heutrall 6' T71' 8····-r9 .. 1", stuffedProtein .T

Veaetable l 'G~n ILipid N. ,I

FruitDairy !

I

., .;"

!~ilj1~(:jL~~C~jl;ij::·iji(srrempty r2l3ln~,neut~ 617T 8 r 9 I stuffedProtein -:1;

Vegetable I; .Grain l'.Lipid N. II iFru~ :

.'

Dairy I I I!

fiii!;.4~~~~:24=:Lj..-""'';-':''~'''-...:.L_-il'----lL.:..--''''-...I.-'''''''';-L''''';'''...:.L_ .._8.,-'' 1<9.,lstUff!ld

'[

.",

Anger· ..·

'" .;

I

, ~

::(:i:!:i;},:!'''i:;~SNA(l~n:,;!);~:ITf~mpty r~'''TYl1r4'lneutral] 6T, 7T'8 .. r·9 1 .stuffed. Protein ,. ;! .Vegetable , ;.

Grain IiLipid N. . IiFruit Ii '.Dairy ,t

. .

:1;M:;i~:!1:i:y'"TA~"~~:;';%~tNI !iyes no

I~JIo'q ....ii"~I

./ "

Joy

Urge to quittxlrecovery

I Lying!. Withholding

.1

Protocols

Y. N·.Y'. N,Y N.

'"

,,',

~~,,:. . :"~';.'