FOOD DIARY Protocol: _____ Subject: ____________ Date Received: _________ Taking Supplements: Y or N

C E F Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking Comments Day prepared Be specific …. Give details Method A B C D E F Time of Day Indicate Where Food Was Prepared H = Home R = Restaurant PLEASE PROVIDE THE NAME OF THE RESTAURANT O = Other (Please Explain) Description of Food or Beverage RECORD ONE FOOD ITEM PER LINE! BE SPECIFIC … GIVE DETAILS DIRECTIONS FOR KEEPING YOUR FOOD DIARY. Please keep a food record for three consecutive days. These should include 2 workdays and 1 non-work day. Write down EVERYTHING you eat or drink each day. This includes all meals, snacks, nibbling, sodas, cocktails, etc. Always record in your diary after having a meal, snack, or drink. PLEASE WRITE LEGIBLY. Indicate Amounts Use Measuring Spoons For: jelly, sugar, syrup, gravy, salad dressings, butter, margarine, and condiments (3 tsp = 1 Tbsp) Use Measuring Cups (volume) For: vegetables, rice, noodles, cereals, soups, stews, casseroles, ice cream, jello, canned fruit and beverages (1 cup = 8 fluid ounces) Use Ounces (weight) For: Meat, fish, poultry, cheese, tofu, pizza, salad items, cakes, cookies, and brownies or give dimension using a ruler Use Number and Size (Sm, Med, Lg) For: breads, rolls, raw fruit, hot dogs, lunch meats, crackers, chips and candy Indicate Cooking Method baked, broiled sautéed, fried, or microwaved Reviewer’s Comments Please do not write in space. B D A

Please write legibly. Patient Initials: JLB Date of Diary: 1/28/03 Day of the Week: Tuesday A B C D E F Time Indicate where Description of Food Indicate Indicate Reviewer’s Of the food was (Record one food item per line) Amounts Cooking Comments Day prepared Be specific.. Give details Method 7:00 AM H Coffee – Regular 12 Fl. Oz. Cream – Half & Half1 tsp.Fat free Sugar – (White) 1 tsp. OJ – plus Calcium + Pulp 6 oz. Oroweat – 12 grain1 Slice Toasted 5:30 PMR - Maui Steak 3 ounces Marinated in teriyaki sauce Wahoo’s White rice 1 cup Fish Tacos Black beans1 cup Margarita, No Salt6 fluid ounces 10:00 AMStarbucksSoy Chai12 oz.Tall 11:30 AM H KS Crusty Onion Rye Bread56 grams Kraft Mayo “Light”2 tsp. Oscar Mayer Bacon4 StripsMicrowave Tomato – Small3 Slices¼ inch slices Lettuce 1 Leafromaine Lays Potato Chips (BBQ Flavor)25 Each (2.5 ounces) Grapes – Green1 cupgreen/seedless Gatorade, Lemon-Lime32 oz. 7:40 PMHCheese Cake – Homemade1/12 of 9 inch Pie (128 grams) Milk - 1%8 oz 9:00 PM HNabisco – Saltines Crackers4 Each HHershey Kisses w/Almonds2 Each TOTAL WATER INTAKE FOR THE DAY: 72 Ounces

BRAND NAMES

BE SPECIFIC BRAND NAME

CEREALS

B O W L O F C E R E A L

I had a BOWL of LIFE cereal! OK! How much does your bowl hold in terms of cups? Or, better yet weigh it out!