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Completing Your PAL Forms

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PAL Forms

• PAL: Personal Awareness Log• Paperwork you will be COMPLETING and

TURNING IN on a weekly basis during Stage I of the Dr. Dean Ornish Program for Reversing Heart Disease.

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The Benefits of PAL and Other Forms• Research shows that self-monitoring is one of the

most important tools used for succeeding at lifestyle change.

• Self-monitoring using PAL and other forms helps you:– Outline clear goals for nutrition, exercise, group and

stress management.– Self-assess how you are doing on a daily basis.– Recognize and celebrate the areas in which you’re

doing well.– Identify the areas in which you need to focus.

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Is all this paperwork necessary?

• The PAL forms assist the Ornish team in:– identifying any barriers– helping you reach goals – customizing the Program to meet your needs

• Careful monitoring will ensure good nutrition and safe and effective participation in all four elements as well as ensure maintenance to lifestyle change.

• The PAL forms are a tool to help the Ornish team help you. – They are not meant to be judgmental.

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How to Complete Your

Nutrition PAL Formand Weekly Food Diary

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Step 1: Identify the foods you have eaten and the amount consumed.

• Sample Dinner Meal– 1 Boca Burger on 1 Whole-Wheat Bun

• 1 Tbsp ketchup, 1 lettuce leaf, 1 tomato slice

– ½ cup Vegetarian Baked Beans– 1 cup Field Green Salad

• 2 Tbsp fat-free French dressing

– 1 cup Fresh Cubed Melon

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Step 2: Determine corresponding food groups based on the Reversal Food Pyramid.

Food Eaten Food Group

Boca Burger Protein

Whole-Wheat Bun Whole Grain

Lettuce, Tomato Vegetable

Vegetarian Baked Beans Protein

Field Green Salad Vegetable

Fat-free French Dressing Free Food

Melon Fruit

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SERVING SIZE reference found on back of Nutrition PAL Form.

Step 3: Determine the amount of servings eaten.

Food Eaten Food Group # Servings

Boca Burger Protein 1 burger = 1 svg

Whole-Wheat Bun Whole Grain 1 bun = 2 svg

Lettuce, Tomato Vegetable1 piece lettuce,

1 tomato slice = < 1 svg

Vegetarian Baked Beans Protein ½ cup = 1 svg

Field Green Salad Vegetable 1 cup = 1 svg

Fat-free French Dressing Free Food 2 Tbsp = 1 svg

Fresh Cubed Melon Fruit 1 cup = 1 svg

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Step 4: Record information on food diary.

Food EatenFood

Group# Servings

WW Bun Whole Grain 1 bun = 2 svg

Lettuce, Tomato Vegetable1 piece lettuce, 1 tom. slice = <

1 svg

Field Green Salad Vegetable 1 cup = 1 svg

Fresh Melon Fruit 1 cup = 1 svg

Boca Burger Protein 1 burger = 1 svg

Veg. Baked Beans Protein ½ cup = 1 svg

FF French Drsg Free Food 2 Tbsp = 1 svg

WEEKLY FOOD DIARYGrains (6+ whole grains)1 whole wheat bun (2)Vegetables (3+)1 lettuce, 1 tomato slice (<1)1 cup field greens (1)Fruits (2-4)I cup melon (1) Full Fat Soy (1)

Other Protein (1-3)I Boca Burger (1) I/2 cup veg baked beans (1) Nonfat Dairy (0-2)

Sweets (0-2)/Alcohol (0-1)

Free Food:2 T FF French dressing (1)

Record all meals and snack.

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Step 5: Transfer servings to Nutrition PAL Form.

Protein Sources

Food Group

Servings

Whole Grains

6 or more

Veggie

3 or more

Fresh Fruit

2 to 4

Full Fat Soy Food

1

Other Protein Foods*

1 to 3

NonfatDairy

0 to 2

Sweets

0 to 2

Mon 8 4+ 3 1 2 1 0

Tues

Wed

Thurs

10

Food Group

Servings

Low-Fat Foods

<3g Fat**

0 to 3

Suppl

√ for all

NO

Caffeine

LIMITED

Alcohol

FO

OD

GR

OU

P

TO

TA

L

Mon 1 0 0Tues

Wed

Thurs

Step 5: Continued

MAJOR GUIDELINES:

Please indicate if you were able to follow the nutrition guidelines with a Y (YES) or N (NO).

NO

ADDED FAT

AND OIL

NO

MEAT

FISH

POULTRY

DIE

TA

RY

GU

IDE

LIN

E

TO

TA

L

Y Y

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Leave shaded areas blank. For staff use.

Know Your PAL Form

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Low-Fat Foods ≤ 3 grams Fat Per Serving

LOW-FAT FOOD = An Ornish-friendly food with 3 grams of fat or less per serving, which also contains trace amounts of unsaturated fat(s) as a minor ingredient. 0-3 SERVINGS ALLOWED/DAY.

Veggie PenneNutrition Facts

Serving Size: 1 package (300g)

Calories 220 Calories from Fat 15

Total Fat 1.5g

Saturated Fat 0g

Cholesterol 30mg

Sodium 730mg

Total Carbohydrate 36g

Dietary Fiber 4g

Sugars 7g

Protein 12g

INGREDIENTS:WATER, TOMATOES, ENRICHED PENNE PASTA (DURUM SEMOLINA, NIACIN, FERROUS SULFATE (IRON), THIAMINE MONONITRATE, RIBOFLAVIN, FOLIC ACID), ROASTED RED PEPPERS, ONIONS, TEXTURED SOY PROTEIN (NON-GMO), TOMATO PASTE, BURGUNDY WINE, TEXTURED WHEAT PROTEIN, ROASTED GARLIC, SALT, ORGANIC EVAPORATED CANE JUICE, CORNSTARCH, SPICES, EXPELLER PRESSED OLIVE OIL, NATURAL FLAVOR, MALT EXTRACT, CITRIC ACID, GARLIC POWDER, ONION POWDER, CARRAGEENAN (FROM SEAWEED), SESAME OIL.

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INGREDIENTS:WATER, SOY PROTEIN CONCENTRATE, WHEAT GLUTEN, CONTAINS LESS THAN 2% OF NATURAL FLAVOR, SALT, MALTODEXTRIN, DRIED ONION, YEAST EXTRACT, SESAME OIL, DEFATTED WHEAT GERM, CARAMEL COLOR, HYDROLYZED CORN, SOY AND WHEAT GLUTEN, SOY SAUCE (WATER, SOYBEANS, WHEAT, SALT), AUTOLYZED YEAST EXTRACT, NATURAL AND ARTIFICIAL FLAVOR (CONTAINS COTTONSEED), METHYLCELLULOSE, DISODIUM GUANYLATE, DISODIUM INOSINATE, SUCCINIC ACID 

Nutrition Facts:

Serving Size: 1 burger (71g)Servings Per Container: 4

Amount Per ServingCalories 90 Calories from Fat 10

Total Fat 1g

Saturated Fat 0g

Cholesterol 0mg

Sodium 350mg

Total Carbohydrate 6g

Dietary Fiber 4g

Sugars 0g

Protein 13g

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3 1

Weekly Food Diary Name: ________________MondayFood & Amount:

Other Grains1 cup Yves Veggie Penne **

Vegetables (3+)½ cup tomato sauce

Fruits (2-4)

Full Fat Soy (1)

Other Protein (1-3)1 Boca Burger (1) *

Nonfat Dairy (0-2)

Low fat Foods (0-3)1 Boca Burger (1)2 servings Yves Veggie Penne

Sweets (0-2) / Alcohol (0-1)

1

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Tips for Nutrition PALs:• Always include accurate amounts for all foods and

beverages recorded. Don’t forget snacks or drinks.• Save food labels and bring them to the next session if

unsure of a packaged food.• Always refer to the serving sizes listed of the back of the

Nutrition PAL form when estimating servings.• Write legibly.• Be as accurate and descriptive as possible, using “FF” for

fat-free foods, “WG” or “WW” for whole-grains and whole- wheat foods.

• Indicate whether vegetables are cooked or raw, and fruits are fresh or canned.

Stress Management, Exercise and

Group Support

PAL Forms

Sample Week PAL FormMONDAY

• 30 minutes meditation

• 30 minutes yoga poses

• 45 minutes swimming

TUESDAY – CLASS

• 60 minutes – Ornish yoga class

• 50 minutes treadmill

WEDNESDAY – BAD DAY!

• 15 minutes deep breathing

THURSDAY – CLASS

• 60 minutes Ornish yoga class

• 45 minutes treadmill

FRIDAY

• 15 minutes imagery

• 15 minutes deep relaxation

• 15 minutes yoga poses

• 40 minutes biking

SATURDAY

• 60 minutes relaxation/yoga CD

• 30 minutes resistance band

SUNDAY

• 60 minutes relaxation/yoga CD

01/02/09

30 30 60

45

treadmill

14

50 12 treadmill

60

15 sitting in traffic 15

60

15 15 15

Relax CD

30

30

12

12

8

8

2

2

8

8

60

60

45

360 51 minutes

bike 40 14

swim

45 14

bands 30 12

180 minutes

yard 30

yard 30

2

3

3

4 4

4

4

24

4

25

Ornish yoga class

Ornish yoga class

4

6 5

2

4

Relax CD

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More PAL Tips

• Total your weekly minutes for stress management and exercise.

• Don’t forget to record exercise and stress management done during weekly class time.

• Add comments about encounters or stressful situations you may have had during the day/week.

• Write down any questions or concerns you may have during the week on the back of any one of your forms for the staff to address.

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Questions

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