Daily Record of Food Intake Form Please enable JavaScript in your browser to complete this form.Each day, record all the items you eat and 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 *FirstLastDAY 1Date:Day 1BREAKFAST 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 - goodDAY 2Date:Day 2BREAKFAST 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 - poor, 5 - goodDAY 3Date:Day 3BREAKFAST 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 - poor, 5 - goodDAY 4Date:Day 4BREAKFAST 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 - poor, 5 - goodDAY 5Date:Day 5BREAKFAST 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 - poor, 5 - goodDAY 6Date:Day 6BREAKFAST 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 - poor, 5 - goodDAY 7Date:Day 7BREAKFAST 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 - poor, 5 - goodPhoneSubmit