Multiple Day Food Record ID # ____________________________ SAMPLE
Multiple Day Food Record
ID # ____________________________
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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.
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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
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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)
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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
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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
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8
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
1
2
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
1
2
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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10
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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11
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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12
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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15
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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16
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
1
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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17
Day: ____________________________________ Date: ____/____/____
FooD anD BEvERaGES aMount
1
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MeAlB = BrkfastL = LunchD = DinnerS = Snacks
PlACe PrePAreDH = HomeR = RestaurantO = Other
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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
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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
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