Name ____________________ Age ____________________ Height ___________________Weight __________________

Food Record Instructions

1. Record food and beverage intake for three consecutive days. If possible, include two weekdays and one weekend day (i.e.- Thurs. !ri. "at. or "un. #on. Tues.$. %. &'ease record everything you eat and drink immediately after mea'. ((o not try to reca'' everything at the end of the day$ ). The more detai's you *rovide+ the more accurate your dietary ana'ysis ,i'' be and your nutritiona' *'an to meet your goa's. Record *ortion si-e using units such as 1 cu*+ . cu*+ 1 o-.+ ) ts*.+ % Tbs*. /ou may a'so inc'ude the ounce or gram ,eight information from *ackaged foods if avai'ab'e. "*ecify cooking *re*arations ,hen a**ro*riate (i.e.-baked+ broi'ed+ fried+ etc$. 0nc'ude nutritiona' 'abe' ,hen a**ro*riate (i.e. 1 internationa' foods+ 2uni3ue4 foods$. 0t is 56 to use name brands of fast food mea's. (i.e. 1 #c(ona'ds 7ig N8 Tasty$ (o not forget added condiments (i.e. sa't+ sugar+ *e**er+ mayo+ etc.$

9. An e:am*'e recording is be'o,.

Example Day
Time ;<)= A# 1=<== A# 1%<== A# Food Item !rosted #ini Wheats (#edium si-e$ #i'k (!at !ree >ucerne$ 5range ?uice (*u'*'ess+ #inute#aid$ &o*tart (untoasted+ 7'ueberry$ Ara*es (red+ seed'ess$ Water bott'e 1% o-. &e*si (diet$ "and,ich 1 bread (&e**erdine !arm+ french+ Cnriched$ - cheese (!eta cheese$ - mustard (bro,n$ - ham (@D fat roasted$ - 'ettuce (romaine$ A**'e Ehoco'ate Ehi* Eookies (To''house+ che,y$ >ays &otato Ehi*s (7aked$ &icante sauce (#i'd$ Water bott'e 1% o-. Portion Size 1.@ cu*s 1 cu* 1 sma'' cu* 1 *ackage (B%$ 1 cu* % fu'' 1 can % s'ices % ounces 1 Tbs*. 9 ounces % 'eaves 1 item 9 items 1 bag % ounces ) fu''

)<== &#

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Eassero'e 1 s*ecific brand+ inc'ude reci*e #i'k (%D >ucerne$

% cu*s F% % cu*s ('arge$

Day 1
Time

Date____________ Food Item

Portion Size

Day 2
Time

Date____________ Food Item

Portion Size

Day 3
Time

Date____________ Food Item

Portion Size