RSS Diabetes Service – Fact sheet                                                                                                     March 2021 
         3 Day food, drink and physical activity diary 
         This diary is a powerful tool to help you become more aware of your eating and drinking habits and physical activity levels. 
           Day 1 Date:                                                    Food                                                                 Drinks                                   Physical activity                     Comments 
                                                     (e.g. 1 slice of white bread, 15gm)                                   (e.g. full cream milk 250mL,15gm)                             (e.g. walk 30mins)                  (e.g. stressors) 
                                                                                                                                                                                                                     
           __________
           Breakfast                                                                                                                                                                                                     
           Time:______am                    
           BG:_____mmol/L 
           Mid-morning                                                                                                                                                                                                   
           Time:______am                    
           BG:_____mmol/L
                                      
           Lunch                                                                                                                                                                                                         
           Time: ______pm                   
           BG:_____mmol/L
                                      
           Mid-afternoon                                                                                                                                                                                                 
           Time:______pm                    
           BG:_____mmol/L 
           Evening                                                                                                                                                                                                       
           Time:______pm                    
           BG:_____mmol/L 
           Supper                                                                                                                                                                                                        
           Time:______pm 
           BG:_____mmol/L
                                      
           Overnight                                                                                                                                                                                                     
           Time:______am                    
                                      
           BG:_____mmol/L
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      Day 2 Date:                            Food                                      Drinks                   Physical activity       Comments 
                                (e.g. 1 slice of white bread, 15gm)        (e.g. full cream milk 250mL,15gm)     (e.g. walk 30mins)    (e.g. stressors) 
                                                                                                                                  
      __________
      Breakfast                                                                                                                      
      Time:______am       
      BG:_____mmol/L 
      Mid-morning                                                                                                                    
      Time:______am       
      BG:_____mmol/L
                       
      Lunch                                                                                                                          
      Time: ______pm      
      BG:_____mmol/L
                       
      Mid-afternoon                                                                                                                  
      Time:______pm       
      BG:_____mmol/L
                       
      Evening                                                                                                                        
      Time:______pm       
      BG:_____mmol/L 
      Supper                                                                                                                         
      Time:______pm 
      BG:_____mmol/L
                       
      Overnight                                                                                                                      
      Time:______am       
                       
      BG:_____mmol/L
    
     Notes: 
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              Day 3 Date:                                                                                  Food                                                                                                  Drinks                                                      Physical activity                                        Comments 
                                                                             (e.g. 1 slice of white bread, 15gm)                                                                    (e.g. full cream milk 250mL,15gm)                                                         (e.g. walk 30mins)                                   (e.g. stressors) 
                                                                                                                                                                                                                                                                                                                       
              __________
              Breakfast                                                                                                                                                                                                                                                                                                       
              Time:______am                                    
              BG:_____mmol/L 
              Mid-morning                                                                                                                                                                                                                                                                                                     
              Time:______am                                    
              BG:_____mmol/L
                                                      
              Lunch                                                                                                                                                                                                                                                                                                           
              Time: ______pm                                   
              BG:_____mmol/L
                                                      
              Mid-afternoon                                                                                                                                                                                                                                                                                                   
              Time:______pm                                    
              BG:_____mmol/L
                                                      
              Evening                                                                                                                                                                                                                                                                                                         
              Time:______pm                                    
              BG:_____mmol/L 
              Supper                                                                                                                                                                                                                                                                                                          
              Time:______pm 
              BG:_____mmol/L
                                                      
              Overnight                                                                                                                                                                                                                                                                                                       
              Time:______am                                    
                                                      
              BG:_____mmol/L
       
            For more information 
            Diabetes Service 
            Rural Support Service 
            PO Box 287, Rundle Mall 
            ADELAIDE  SA  5000 
            Telephone: (08) 8226 7168 
            www.chsa-diabetes.org.au 
            www.sahealth.sa.gov.au/regionalhealth  
             
            © Rural Support Service, SA Health, Government of South Australia. All rights reserved.                                                                                       Public-I3-A2 
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                                                                                                                                                     Disclaimer: This resource is not a substitute for, nor is it intended to replace, the services of a qualified health practitioner.