Heart Failure: Track Your Weight, Food, and Sodium

Use this form to record the sodium content of the foods you eat or drink each day. This record will help you see whether you are getting too much sodium in your diet. Use the Nutrition Facts on food labels to help find how much sodium you eat.

You can tell when your body retains fluid by weighing yourself often. Sodium "attracts" fluid, so the more sodium you consume, the more fluid you will retain. When your body retains fluid, your weight may increase.

If you weigh yourself every day, you can tell when your body is retaining fluids because you will weigh more. Record the date and your weight on this form daily.

Take this record with you when you see your doctor or registered dietitian.

My doctor recommends that I have ___________milligrams (or ______ grams) of sodium in my diet each day.

Week of __________________.

Date and weight. Foods and drinks consumed during the day. Milligrams (or grams) of sodium in each meal or snack.

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

______________________________

Lunch _________________________

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Dinner _________________________

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Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

 

Breakfast ______________________

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Lunch _________________________

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Dinner _________________________

______________________________

Snacks ________________________

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Breakfast ________


Lunch ___________


Dinner ___________


Snacks ___________

Total sodium for the day: _______

ByHealthwise Staff
Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
Martin J. Gabica, MD - Family Medicine
Specialist Medical Reviewer Colleen O'Connor, PhD, RD - Registered Dietitian

Current as ofJanuary 27, 2016