MEASUREMENTS BEFORE DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8

My Weight (pounds)
My Waist size (measure at the widest part, around your belly
button)
My Hip Width (measure around the widest part)

My Thigh Width (measure around the widest part)

My Blood pressure

My Blood sugar (optional; this is done ideally before breakfast and

repeated 2 hours after you’ve eaten. You can also do this 2
hours after dinner to see how your meal affects your blood sugar.)

LIFESTYLE

How much sleep I got the night before and how well I slept
(deeply or restlessly
How many minutes of exercise I did today

What type of exercise I did today (interval? strength training?)

How many minutes I spent on the relaxation practices

What type of relaxation I used (meditation? Take 5 breath work?)

Observations I noticed from doing the above

SUPPLEMENTS (take with morning shake)

Option 1 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Pure Lean Pack by Pure Encapsulations with breakfast

Vitamin D3 1000 U by Pure Encapsulations 2 caps with breakfast

Option 2 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Wellness Essentials for Healthy Balance by Metagenics with
breakfast
Vitamin D3 1000 U by Pure Encapsulations 2 caps with breakfast

PGX (powder or capsules) - 2.5-5 grams just before each meal;

optional additional dose after dinner if needed to control cravings ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Breakfast (just before) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Lunch (just before) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Dinner (just before) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
ELIMINATION

How many bowel movements?

F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐
(F)ormed, (L)oose, (C)onstipation, (D)iarrhea, (G)as, (B)loating
G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐ G☐ B☐
FOOD DIARY

Breakfast (shake)

Food I ate & Beverage(s) I drank [NEED MORE SPACE HERE]

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being (Scale 1 - 10)

Page 1 of 4
MEASUREMENTS BEFORE DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8

Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Mid - Morning Snack (1 ounce raw nuts and/or seeds)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

I wasn't hungry. My alternative source of nourishment was…

Lunch (soup, Dr. Hyman's salad bar or adventure plan)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Afternoon Snack (smear or spread with mixed crudite)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

I wasn't hungry. My alternative source of nourishment was…

Dinner (core or adventure plan)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Page 2 of 4
 DIFFERENCE
MEASUREMENTS DAY 9 DAY 10 AFTER
Day 1 to 10
My Weight (pounds)
My Waist size (measure at the widest part, around your belly
button)
My Hip Width (measure around the widest part)

My Thigh Width (measure around the widest part)

My Blood pressure

My Blood sugar (optional; this is done ideally before breakfast and

repeated 2 hours after you’ve eaten. You can also do this 2
hours after dinner to see how your meal affects your blood sugar.)

LIFESTYLE

How much sleep I got the night before and how well I slept
(deeply or restlessly
How many minutes of exercise I did today

What type of exercise I did today (interval? strength training?)

How many minutes I spent on the relaxation practices

What type of relaxation I used (meditation? Take 5 breath work?)

Observations I noticed from doing the above

SUPPLEMENTS (take with morning shake)

Option 1 ☐ ☐
Pure Lean Pack by Pure Encapsulations with breakfast

Vitamin D3 1000 U by Pure Encapsulations 2 caps with breakfast

Option 2 ☐ ☐
Wellness Essentials for Healthy Balance by Metagenics with
breakfast
Vitamin D3 1000 U by Pure Encapsulations 2 caps with breakfast

PGX (powder or capsules) - 2.5-5 grams just before each meal;

optional additional dose after dinner if needed to control cravings ☐ ☐
Breakfast (just before) ☐ ☐
Lunch (just before) ☐ ☐
Dinner (just before) ☐ ☐
ELIMINATION

How many bowel movements?

F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐ F☐ L☐ C☐ D☐
(F)ormed, (L)oose, (C)onstipation, (D)iarrhea, (G)as, (B)loating
G☐ B☐ G☐ B☐ G☐ B☐
FOOD DIARY

Breakfast (shake)

Food I ate & Beverage(s) I drank [NEED MORE SPACE HERE]

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being (Scale 1 - 10)

Page 3 of 4
 DIFFERENCE
MEASUREMENTS DAY 9 DAY 10 AFTER
Day 1 to 10
Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Mid - Morning Snack (1 ounce raw nuts and/or seeds)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

I wasn't hungry. My alternative source of nourishment was…

Lunch (soup, Dr. Hyman's salad bar or adventure plan)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Afternoon Snack (smear or spread with mixed crudite)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

I wasn't hungry. My alternative source of nourishment was…

Dinner (core or adventure plan)

Food I ate & Beverage(s) I drank

Time I ate & Time I drank

My hunger level? (Scale 1 - 10)

My Mood Level (Scale 1 - 10)

My Stress Level (Scale 1 - 10)

My emotional well - being

Daily Comments & Notes

I wasn't hungry. My alternative source of nourishment was…

Did I take PGX before this meal?

Page 4 of 4