| Food Record For:_________________________________ |
Date Started:_____________ |
INSTRUCTIONS:
1. Start today (or yesterday) for DAY I and continue for 7 consecutive
days.
2. Write in the type of food (example: grapefruit, carrots, bagel, turkey)
3. Write in the amount of food (example: 4 oz. 8 oz, 1/2 cup beverage, 1 slice cheese,
1 cup french fries, 3/4 cup salad, 1/2 cup corn, etc.)
4. Record butter/mayonaise/jam/peanut butter etc. by teaspoons (tsp) or tablespoons (T)
5. Note the following equivalents: 1 cup = 8 oz., 3 tsp = 1 T., 16 T = 1
cup
Record amounts carefully, but you do not need to measure or weigh foods.
6. Return this sheet as instructed. Thank You.
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| SAMPLE: |
| Whole Milk |
8 oz. |
| Peanut Butter and Jam Sandwich: |
| Bread |
2 slices |
| Peanut Butter |
2 T |
| Jam |
1 Tsp |
| Apple |
1 |
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| FOOD |
DAY 1 |
DAY 2 |
DAY 3 |
DAY 4 |
DAY 5 |
DAY 6 |
DAY 7 |
| MILK |
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| Whole |
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| 2 Percent |
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| Skim/1% |
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| Evaporated |
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| Yogurt (Specify Plain or Fruit) |
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| CITRUS (Fruits, Juice NOT "Ades") |
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| NON-CITRUS FRUIT/JUICE |
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| POTATOES |
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| Potatoes |
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| Fries/Chips/Corn chips |
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| PASTA (Cooked Amount) |
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| RICE (Cooked Amount) |
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| VEGETABLES |
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| Vegetables |
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| Salad |
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| Soup (All Types) |
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| Juice |
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| FOOD |
DAY 1 |
DAY 2 |
DAY 3 |
DAY 4 |
DAY 5 |
DAY 6 |
DAY 7 |
| BREADS |
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| Bread |
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| Roll/Muffin/Tortilla |
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| Waffle/Pancake |
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| Soda Cracker/Other Cracker |
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| Hamburger/Hotdog Bun |
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| CEREALS |
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Whole Grain, Cooked/Uncooked
Shredded Wheat/Granola |
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| Refined (All Varieties) |
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| BUTTER/FATS |
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| Bacon |
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| Cream/Whipping Cream |
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| Mayonaise/Mayonaise Type |
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| Salad Dressing (Oil Type) |
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| Cream Cheese |
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MEAT/FISH/LIVER/POULTRY
Specify Type and Amount as
Purchased Uncooked
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PROTEIN SANDWICH FILL
(Specify)
Tuna Salad, Egg Salad, Wiener,
Cold Cuts, Cheese, Etc.
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| EGG |
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| CHEESE (All Kinds) |
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| Cottage Cheese |
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| PEANUT BUTTER/NUTS/SEEDS |
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| OTHER PROTEIN |
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| Beans, Baked |
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| Legumes |
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Pizza (Portion of # inch)
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| FOOD |
DAY 1 |
DAY 2 |
DAY 3 |
DAY 4 |
DAY 5 |
DAY 6 |
DAY 7 |
| SUGAR/HARD CANDIES |
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| OTHER SWEETS |
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| Jello |
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| Jams/Jellies/Marmalade |
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| Honey/Molasses/Syrup |
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| PASTRY/CAKE/COOKIE/SWEET ROLL/DONUT/ETC (Specify) |
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| MILK DESSERT |
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| Ice Cream |
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| Pudding |
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| CHOCOLATE BARS (Specify) |
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| BEVERAGE (Specify) |
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| Soft Drinks, Fruit "Ades", Beer |
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| Wine |
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| Alcohol |
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| POPCORN POPPED |
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| GRAVY |
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| OTHER |
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