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Patient Education

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Heart Failure: Track Your Weight, Food, and Sodium

Topic Overview

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 ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Date:_______

Weight:_______

Breakfast ______________________

______________________________

Lunch _________________________

______________________________

Dinner _________________________

______________________________

Snacks ________________________

______________________________

Breakfast ________

Lunch ___________

Dinner ___________

Snacks ___________

Total sodium for the day: _______

Credits

Current as ofJuly 22, 2018

Author: Healthwise Staff
Medical Review: Rakesh K. Pai, MD - Cardiology, Electrophysiology
Martin J. Gabica, MD - Family Medicine
Adam Husney, MD - Family Medicine
George J. Philippides, MD, FACC - Cardiology