DAILY RECORD OF FOOD INTAKE

Your diet may be the key to better health!

Each day, Record all the items you eat & drink. Be sure to include the approximate amount of each item.When you have completed this form, Return it to your health care professional for evaluation.

Name *

First

Last

Gender *

Age *

Email *

Phone *

DAY 1

Date / Time

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Meat & Dairy (copy)

Vegetables & fruits

Vegetables & fruits (copy)

ChoiceBread, Cereals, grains

ChoiceBread, Cereals, grains (copy)

Fats(Butter, Margarine, Oil etc)

Fats(Butter, Margarine, Oil etc) (copy)

Candy, Sweets & Junk Foods

Candy, Sweets & Junk Foods (copy)

Water Intake(fl.oz)

Water Intake(fl.oz) (copy)

Other Drinks

Other Drinks (copy)

Morning Snack Time

Midday Snack Time

Night Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 2

Day-2 Date:

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Vegetables & Fruits

ChoiceBread, Cereals, grains

Fats(Butter, Margarine, Oil etc)

Candy, Sweets & Junk Foods

Water Intake(fl.oz)

Other Drinks

Morning Snack Time

Midday Snack Time

Dinner Snack Time

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 3

Day-3 Date:

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Vegetables & Fruits

ChoiceBread, Cereals, grains

Fats(Butter, Margarine, Oil etc)

Candy, Sweets & Junk Foods

Water Intake(fl.oz)

Other Drinks

Morning Time Snack

Lunch Time Snack

Dinner Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 4

Day-4 Date:

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Vegetables & Fruits

Vegetables & Fruits (copy)

ChoiceBread, Cereals, grains

ChoiceBread, Cereals, grains (copy)

Fats(Butter, Margarine, Oil etc)

Fats(Butter, Margarine, Oil etc) (copy)

Candy, Sweets & Junk Foods

Candy, Sweets & Junk Foods (copy)

Water Intake(fl.oz)

Water Intake(fl.oz) (copy)

Other Drinks

Other Drinks (copy)

Morning Time Snack

Lunch Time Snack

Dinner Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 5

Date / Time (copy) (copy)

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Meat & Dairy (copy)

Vegetables & Fruits

ChoiceBread, Cereals, grains

ChoiceBread, Cereals, grains (copy)

Fats(Butter, Margarine, Oil etc)

Candy, Sweets & Junk Foods

Candy, Sweets & Junk Foods (copy)

Water Intake(fl.oz)

Water Intake(fl.oz) (copy)

Other Drinks

Other Drinks (copy)

Morning Time Snack

Lunch Time Snack

Dinner Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 6

Day-6 Date:

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Meat & Dairy (copy)

Vegetables & Fruits

Vegetables & Fruits (copy)

ChoiceBread, Cereals, grains

ChoiceBread, Cereals, grains (copy)

Fats(Butter, Margarine, Oil etc)

Fats(Butter, Margarine, Oil etc) (copy)

Water Intake(fl.oz)

Water Intake(fl.oz) (copy)

Other Drinks

Other Drinks (copy)

Morning Time Snack

Lunch Time Snack

Dinner Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

DAY 7

Day-7 Date:

BREAKFAST time

LUNCH time

DINNER time

Meat & Dairy

Meat & Dairy (copy)

Vegetables & Fruits

Vegetables & Fruits (copy)

ChoiceBread, Cereals, grains

ChoiceBread, Cereals, grains (copy)

Fats(Butter, Margarine, Oil etc)

Fats(Butter, Margarine, Oil etc) (copy)

Candy, Sweets & Junk Foods

Candy, Sweets & Junk Foods (copy)

Water Intake(fl.oz)

Water Intake(fl.oz) (copy)

Other Drinks

Other Drinks (copy)

Morning Time Snack

Lunch Time Snack

Dinner Time Snack

Bowel Movements (number & Consistency)

Hour Of Sleep

Quality of Sleep (good 1-5 Poor)

Email *

DAILY RECORD OF FOOD INTAKE

Your diet may be the key to better health!

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

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