3-Day Food Diary and Instructions

It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.

• Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
• Record information as soon as possible after the food has been consumed.
• Describe the food or beverage as accurately as possible e.g., milk - what kind? (whole, 2%, nonfat); toast (whole wheat, white, buttered); chicken (fried, baked, breaded); coffee (decaffeinated with sugar and 1/2 & 1/2).
• Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
• Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
• Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
• Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc.)
• Please note all bowel movements and their consistency (regular, loose, firm, etc.)

DAY 1

DAY 2

DAY 3