Multiple Day Food Record

ID # ____________________________

SAMPLE

2

General Instructions

• Pleaseeatasyouusuallyeat.

• Recordeverythingyoueatanddrink,includingsnacks.

• CompletetheMeal andPlace Preparedcolumnsforeachmealorsnack.Pleasewriteinnameofrestaurantifyouknowit.

• Starteachnewdayonanewpage.

• Pleasewriteclearly.

How to Record Each Food

• Describeeachfoodandbeverageindetail,asbestyoucan.

IncluDE FoR ExaMplE

How prepared Fried,grilled,breaded,etc.

Added fats Friedinbutter

Brand name Stouffer’sFrozenLasagnawithMeat&Sauce

Portion size½cup, 4oz.[weightfrompackage], 1"x3"x2"cube

• Describeeachingredientinamixeddishorusepage18:

Chicken Caesar Salad3cupsromaine,1mediumchickenbreast(noskin)grilled,¼cupcaesardressing,2Tbsp.parmesancheese,6largecroutons

Spaghetti & Meat Balls1½cupscookedspaghetti,4meatballs(1"diameter),½cupRagumeatlessspaghettisauce,1Tbsp.parmesancheese

• Forhelpwithportionsizes,useFive Ways to Size up Your Servings (onnextpage)andtheruleronthebackofthisbooklet.

SAMPLE

==

=

=

=

3

Five Ways to Size up Your Servings

3ouncesofmeatisaboutthesizeandthicknessofadeckofplayingcards.

1ounceofcheeseisaboutthesizeof4stackeddice.

½cupoficecreamisaboutthesizeofaracquetballortennisball.

1cupofmashedpotatoesorbroccoliisaboutthesizeofyourfist.

1teaspoonofbutterorpeanutbutterisaboutthesizeofthetipofyourthumb.

3 oz.

1 oz.

½ c.

1 c.

1 tsp.

1

2

3

4

5© National Dairy Council

SAMPLE

4

General Questions

Pleasecheck(✔)below.

usually / always Sometimes

Rarely / never

1. Whenyoueatbreadorrolls,howoftendoyouaddbutterormargarine?

2. Whenyoucookvegetables,howoftendoyouaddoil,margarineorbutter?

3. Whenyoueatvegetables,howoftendoyouaddoil,butterormargarineatthetable?

4. Whenyoueatpotatoes,howoftendoyouusebutter,margarine,orsourcream?

5. Howoftendoyouusemilkorcreamincoffeeortea?

6. Whenyoueatchickenorturkey,howoftendoyoueattheskin?

7. Whenyoueatbeef,pork,hamorlamb,howoftendoyoueatthefat?

8. Whenyoueatsalads,howoftendoyouusedressing?SAMPLE

5

What type of milk, spreads and cooking oils did you use while keeping this record?

Pleasespecifyonlythetypeyouusemostoften.Pleasecheck(✔)below.

1. Milk (include all types—cow milk, acidophilus, and soy milk):

Whole 2% 1% Skim Didn’tuse

Other_______________________

2. Margarine (please check one box for a and one box for B):

Stick Tub Squeeze Spray Didn’tuse

Regular Light Fat-free Didn’tuseBrandname____________________

3. Real Butter:

Regular Whipped Light Didn’tuse

4. Salad Dressing:

Regular Diet/low-fat Fat-free Didn’tuseBrandname____________________ Type____________________

5. oil:

Canolaoil Cornoil Oliveoil Saffloweroil

Soybeanoil Otheroil Didn’tuse

6. Mayonnaise:

Regular Diet/low-fat Fat-free Didn’tuseBrandname____________________

7. Did you use a scale to weigh foods?

Yes No

a)

B)

SAMPLE

6

FooD anD BEvERaGES aMount

1 B R Denny’s® buttermilk pancakes, about 6" across ea. 2

2 Butter, whipped 2 tsp

3 Maple syrup ¼ cup

4 Bacon, 6" long 2 strips

5 Coffee, decaffeinated 2 cups

6 Half & half 2 Tbsp

7 S R Starbucks® tall latté, made with 2% milk 12 oz.

8 L H Ham sandwich

9 Rye bread, regular size 2 slices

10 Ham (from the Albertson’s deli) 3 slices

11 Kraft® American cheese slice 1 slice

12 Best Foods® light mayonnaise 2 tsp

Day: ____________________________________ Date: ____/____/____

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

Saturday (example) 11 5 09

SAMPLE

7

Day: ____________________________________ Date: ____/____/____Saturday (example), continued 11 5 09

FooD anD BEvERaGES aMount

1 Doritos® regular tortilla chips 12 chips

2 Salsa ¼ cup

3 Lemonade , reconstituted from frozen 10 oz.

4 Chips Ahoy® chocolate chip cookies, 3" diameter 2 cookies

5 D H Chicken Broccoli Casserole (see recipe on page 18) 1 serving

6 Salad:

7 Romaine lettuce 1 cup

8 Tomato ¼ med

9 Kraft® Italian fat free salad dressing 1 Tbsp

10 Potato wedges, roasted in olive oil 1 cup

11 Ketchup, regular 1 Tbsp

12 S HYellow cake with chocolate frosting ,

3.5" L x 2" W x 1.25" thick1 cube

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

8

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

9

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

10

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

11

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

12

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

13

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

14

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

15

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

16

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

17

Day: ____________________________________ Date: ____/____/____

FooD anD BEvERaGES aMount

1

2

3

4

5

6

7

8

9

10

11

12

MeAlB = BrkfastL = LunchD = DinnerS = Snacks

PlACe PrePAreDH = HomeR = RestaurantO = Other

SAMPLE

18

Recipes:

Ifunsureofservingsmade,thinkofsizeofcontainer.Forexample,a3quartpot=12cups.Howmanycupsdidyoueat?Acasseroledish13x9x2mightbedividedinto12servings.Howmanyservingsdidyoueat?Youdonothavetoincludeseasoningslikesaltandpepper.

ExaMplE: _________________________

#ofservings(1cupeach)made: _______ #ofservings(1cupeach)youate: _______

InGREDIEntS pREpaRatIon aMount

Broccoli, frozen Steamed 15 oz bag Chicken breast, no skin Grilled 4 mediumCream of chicken soup Undiluted One 10.75 oz canCheddar cheese, grated ¼ cupBread crumbs, seasoned 3 tbsp

REcIpE 1: __________________________

#ofservings(1cupeach)made: _______ #ofservings(1cupeach)youate: _______

InGREDIEntS pREpaRatIon aMount

Chicken Broccoli Casserole

6 1

SAMPLE

19

REcIpE 2: __________________________

#ofservings(1cupeach)made: _______ #ofservings(1cupeach)youate: _______

InGREDIEntS pREpaRatIon aMount

REcIpE 3: __________________________

#ofservings(1cupeach)made: _______ #ofservings(1cupeach)youate: _______

InGREDIEntS pREpaRatIon aMount

SAMPLE

1"2"

3"4"

5"6"

7"8"

20

thank you!

For NutritioN ASSeSSMeNt uSe oNly

Coded by ____________________________

Date reviewed ________________________

Reviewed by _________________________

Version 3 © Fred Hutchinson Cancer Research Center

SAMPLE