FOOD

DIARY

Protocol: _____Subject: ____________Date Received: _________Taking Supplements: Y or N

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Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking

CommentsDay prepared Be specific …. Give details Method

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Time of Day

Indicate Where Food Was PreparedH = HomeR = Restaurant PLEASE PROVIDE THE NAME OF THE RESTAURANT O = Other (Please Explain)

Description of Food or BeverageRECORD ONE FOOD ITEM PER LINE!BE SPECIFIC … GIVE DETAILS

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 Amounts

Use Measuring Spoons For:jelly, sugar, syrup, gravy, saladdressings, butter, margarine, andcondiments (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 browniesor give dimension using a ruler

Use Number and Size (Sm, Med, Lg) For:breads, rolls, raw fruit, hot dogs, lunchmeats, crackers, chips and candy

Indicate Cooking Methodbaked, broiledsautéed, fried, or microwaved

Reviewer’s CommentsPlease do not write in space.

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Please write legibly.Patient Initials: JLB Date of Diary: 1/28/03 Day of the Week: Tuesday

A B C D E FTime Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking

CommentsDay prepared Be specific .. Give details Method7:00 AM H Coffee – Regular 12 Fl. Oz.

Cream – Half & Half 1 tsp. Fat freeSugar – (White) 1 tsp.OJ – plus Calcium + Pulp 6 oz.Oroweat – 12 grain 1 Slice Toasted

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

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 MicrowaveTomato – Small 3 Slices ¼ inch slicesLettuce 1 Leaf romaineLays Potato Chips (BBQ Flavor) 25 Each (2.5 ounces)Grapes – Green 1 cup green/seedlessGatorade, Lemon-Lime 32 oz.

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 EachH Hershey Kisses w/Almonds 2 Each

TOTAL WATER INTAKE FOR THE DAY: 72 Ounces

BRAND NAMES

BE SPECIFICBRAND NAME

CEREALS

B O W L O F

C E R E A L

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!