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Food Intake Form Grandma
Food Intake Form Grandma
Part I.
Yes
No
IBS attacks
and
symptoms
Part II.
Please check applicable items and note frequency when indicated
21.
Type of food preparation
_ Conventional Cooking
frequently cook
_ Convenience Foods
convenience food
_ Snack Foods
snack foods
22.
Location of meals
__Home
__Restaurant
Frequency
pt and husband
pt frequently eats
pt frequently consumes
__Other
23.
24.
_____________________
Food Cravings
____ Sweets
_____________________
____ Fried
____ Salty
_____________________
_____________________
Food preferences
____
Ethnic
_____________________
____ Religious
Fish on Fridays during
lent
Pt does not always drink with meals, she carries a 16oz Arrowhead
water bottle and refills it through out the day
Pt is meticulous about keeping a food diary and trying to determine her
trigger foods
Day 1
Hour
8am
12pm
2pm
5pm
Activity
Food Intake
None
(2100mL water
consumed throughout
the day)
None
None
None
Breakfast:
1 whole white English
muffin
2 tsp butter
2 tbs acacia fiber
8oz peppermint tea
Lunch:
McDonalds Filet-O-Fish
Small Fries
Snack 1:
cup sugar free
pudding
3 chessmen shortbread
cookies
Dinner:
Subway 6 tuna
8pm
None
sandwich
light mayo
lettuce/tomato
black olives
pickle
1 Bag Baked lays chips
Snack 2:
1 whole white English
muffin
1 tbs raspberry jam
8oz peppermint tea
Activity
Food Intake
(2100mL water
consumed throughout
the day)
8am
None
Breakfast:
1 Eggo waffle
1 tsp butter
2 tbs Log Cabin Syrup
2 tbs acacia fiber
12pm
2pm
6pm
None
None
Lunch:
3oz Cheese Pizza
Fruit cup juice only
(peaches)
None
Snack 1:
1 Sugarless Popsicle
Dinner:
1 Cup Spaghetti
2oz Meat Sauce
Activity
Food Intake
(2100mL Water
consumed throughout
the day)
9am
None
Breakfast:
1 Packet Instant
Oatmeal (Plain)
1 tbs Skim Milk
1pm
None
Lunch:
1 Frozen Wanton Shrimp
Bowl
1 Sugarless Popsicle
5pm
None
Dinner:
4 oz Cod cooked in
1 tbs olive oil
None
Snack:
1 Bag Weight Watchers
Buttered Popcorn