Weekly Food Summary Please fill in this summary once weekly and submit. Your Name (required) Your Email (required) Week Ending Date (required) Current Weight (lbs.) Breakfast Foods Symptoms Lunch Foods Symptoms Dinner Foods Symptoms Snack Foods Symptoms Do you eat after dinner? NoYes Are you eating more carbs such as pasta, rice, potato, bread? NoYes Are you eating more sweets? NoYes Did you increase fruit consumption? NoYes Please note any concerns or questions Note: The information entered on this page will be sent to Holistic Nutrition Services and to your email address entered above.