prediabetes food diary

Please submit this food diary prior to your appointment. Track all food intake for 3-5 days and include as much information as possible in the chart below.

If you have any questions, please contact us at 937-641-3487.

child's name:

date of birth:

your name:

relationship to the child:

best phone number:

secondary phone number:

email:

Table

Re-order	day/date	time	food eaten (including drinks)	how patient felt half an hour later (e.g. hungry, tired, satisfied, bloated, alert etc…)	Weight	Operations
	day/date	time	food eaten (including drinks)	how patient felt half an hour later (e.g. hungry, tired, satisfied, bloated, alert etc…)	Item weight

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The endocrinology department welcomes phone calls to 937- 641-3487 during our normal business hours of 8:00 am to 5:00 pm. After hours, you can dial 937-641-3000 and ask that the endocrinologist on call be paged.

Schedule you appointment online by visiting our scheduling page. All follow up appointments will be made during your clinic visit or by calling central scheduling at 937-641-4000.

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