Daily Record of Food Intake 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 *

First

Last

DAY 1

Date:

Day 1

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:

Day 2

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 - poor, 5 - good

DAY 3

Date:

Day 3

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 - poor, 5 - good

DAY 4

Date:

Day 4

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 - poor, 5 - good

DAY 5

Date:

Day 5

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 - poor, 5 - good

DAY 6

Date:

Day 6

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 - poor, 5 - good

DAY 7

Date:

Day 7

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 - poor, 5 - good

Phone

Daily Record of Food Intake Form

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

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