Daily Record of Food Intake Form

NUTRITION

Each day, record everything you eat and drink, along with approximate amounts. Once you've completed all seven days, please return the form to your clinician for review and personalized feedback.

Name

First

Last

DAY 1

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 2

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 3

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 4

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 5

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 6

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

DAY 7

Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

LUNCH Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-DAY SNACK Time:

Snack:

DINNER Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

NIGHTTIME SNACK Time:

Snack:

Bowel Movements (# and consistency):

Hours of Sleep:

Quality of Sleep:

Selected Value: 1

1 - poor, 5 - good

Name

NUTRITION