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FOOD DIARY

Protocol: _____ Subject: ____________ Date Received: _________ Taking Supplements: Y or N. FOOD DIARY. A B C D E F. Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking Comments

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FOOD DIARY

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  1. Protocol: _____ Subject: ____________ Date Received: _________ Taking Supplements: Y or N FOOD DIARY

  2. A B C D E F Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking Comments Day prepared Be specific …. Give details Method DIRECTIONS FOR KEEPING YOUR FOOD DIARY. Please keep a food record for three consecutive days. These should include 2 workdays and 1 non-work day. Write down EVERYTHING you eat or drink each day. This includes all meals, snacks, nibbling, sodas, cocktails, etc. Always record in your diary after having a meal, snack, or drink. PLEASE WRITE LEGIBLY. Indicate Cooking Method baked, broiled sautéed, fried, or microwaved E D Time of Day A Indicate Amounts Use Measuring Spoons For: jelly, sugar, syrup, gravy, salad dressings, butter, margarine, and condiments (3 tsp = 1 Tbsp) Use Measuring Cups (volume) For: vegetables, rice, noodles, cereals, soups, stews, casseroles, ice cream, jello, canned fruit and beverages (1 cup = 8 fluid ounces) Use Ounces (weight) For: Meat, fish, poultry, cheese, tofu, pizza, salad items, cakes, cookies, and brownies or give dimension using a ruler Use Number and Size (Sm, Med, Lg) For: breads, rolls, raw fruit, hot dogs, lunch meats, crackers, chips and candy Indicate Where Food Was Prepared H = Home R = Restaurant PLEASE PROVIDE THE NAME OF THE RESTAURANT O = Other (Please Explain) B Reviewer’s Comments Please do not write in space. F Description of Food or Beverage RECORD ONE FOOD ITEM PER LINE! BE SPECIFIC … GIVE DETAILS C

  3. Please write legibly. Patient Initials: JLB Date of Diary: 1/28/03 Day of the Week: Tuesday A B C D E F Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking Comments Day prepared Be specific .. Give details Method 7:00 AM H Coffee – Regular 12 Fl. Oz. Cream – Half & Half 1 tsp. Fat free Sugar – (White) 1 tsp. OJ – plus Calcium + Pulp 6 oz. Oroweat – 12 grain 1 Slice Toasted 10:00 AM Starbucks Soy Chai 12 oz. Tall 11:30 AM H KS Crusty Onion Rye Bread 56 grams Kraft Mayo “Light” 2 tsp. Oscar Mayer Bacon 4 Strips Microwave Tomato – Small 3 Slices ¼ inch slices Lettuce 1 Leaf romaine Lays Potato Chips (BBQ Flavor) 25 Each (2.5 ounces) Grapes – Green 1 cup green/seedless Gatorade, Lemon-Lime 32 oz. 5:30 PM R - Maui Steak 3 ounces Marinated in teriyaki sauce Wahoo’s White rice 1 cup Fish Tacos Black beans 1 cup Margarita, No Salt 6 fluid ounces 7:40 PM H Cheese Cake – Homemade 1/12 of 9 inch Pie (128 grams) Milk - 1% 8 oz 9:00 PM H Nabisco – Saltines Crackers 4 Each H Hershey Kisses w/Almonds 2 Each TOTAL WATER INTAKE FOR THE DAY: 72 Ounces

  4. BRAND NAMES

  5. BE SPECIFIC BRAND NAME

  6. CEREALS

  7. B O W L O F C E R E A L

  8. C E R E A L I had a BOWL of LIFE cereal! OK! How much does your bowl hold in terms of cups? Or, better yet weigh it out!

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