Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Dear Nutritional Analysis Participant:
Thank you for your interest in the Health Education Resource Center’s (HERC) Nutritional
Analysis program! I look forward to providing you with a very pleasant and educational experience,
and am excited to work with you towards healthy nutrition and lifestyle goals.
Included in the Nutritional Analysis packet are several forms that need to be filled out and returned
to the HERC or EIU Health Service at your earliest convenience. These forms include a
Confidentiality Consent, Nutritional Analysis Form, and a 3-Day Food Record.

Confidentiality Consent: This gives Eastern Illinois University and the Nutrition
Education Coordinator or Registered Dietitian permission to perform the Nutritional
Analysis. This form also gives us permission to send your analysis results to the Eastern
Illinois University Health Service, Counseling Center and/or Eating Disorder Team
depending on your results, while keeping your information confidential.

Nutritional Analysis Form: This gives us some basic information about you, your
nutrient intake, and physical activity patterns. This form will provide the Nutrition
Education Coordinator or Dietitian with pertinent information needed to complete the
analysis. This form also gives us information about any nutrition-related health conditions
you may have. Based on the results, you may be referred to one of the EIU Health Service
medical providers or Registered Dietitian.

3-Day Food Record: This form is included in the Nutritional Analysis Form and is used to
assess your current nutrient intake and provides us with general information about your
eating patterns. The more detailed your record is, the more accurate the analysis is.
Please be very detailed when filling out the record. Be sure to include all measurements,
condiments, cooking methods, and beverages consumed. At the end of each food log there
is also a place to track your physical activity for the same days.
I am excited about working with you and look forward to helping you achieve your nutrition goals!
If you have any questions, feel free to contact the Nutrition Education Coordinator at
217-581-7786.
Thanks,
Caroline Weber
Nutrition Education Coordinator
Health Education Resource Center
Phone: 217-581-7786
Fax: 217-581-8330
Email: herc-nutritioned@eiu.edu
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
To: Nutritional Analysis Participant
From: Nutrition Education Coordinator
Please make sure to sign and date this form and return it with the nutritional analysis packet to the HERC,
EIU Health Service, or place it in campus mail in the envelope provided. This form must be filled out and
returned in order to participate in the Nutritional Analysis Program.
CONFIDENTIALITY CONSENT
Nutritional Analysis Program
Any information that is obtained in connection with the Nutritional Analysis Program and that can be
identified with you will remain confidential. This packet will be given to the Nutrition Education
Coordinator or the Registered Dietitian at the Health Education Resource Center. A copy of the results
from the Nutritional Analysis will be added to your medical record at Eastern Illinois University Health
Service. Depending on your analysis results, you may be referred to the Eastern Illinois University
Counseling Center and/or Eastern Illinois University Eating Disorder Team.
If you have any questions, please feel free to contact the Nutrition Education Coordinator at 217-581-7786
or herc-nutritioned@eiu.edu.
I voluntarily agree to participate in the Nutritional Analysis Program.
________________________________________
Printed Name of Participant
________________________________________
Signature of Participant
_________________________
Date
I, the undersigned, have defined and fully explained the confidentially consent to the above participant.
________________________________________
Signature of Nutrition Education Coordinator
Or Registered Dietitian
________________________
Date
For Office Use Only
______________HS
______________CC
____________Other
____________________________________________________________________Provider/Counselor
Copy To_____________________________________________________________________________
Nutritional Analysis 2
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Nutritional Analysis Form
Please answer the following:
Demographic Information
______________________________
PLEASE COMPLETE IN PEN
___________________________
__________
E Number
Date
Name
______________________________
_____________
__________
__________
Local Address
Local Phone
Date of Birth
Age
______________________________
_____________
__________
__________
Height
Gender
EIU E-mail Address
Current Weight
Academic Information
PLEASE COMPLETE IN PEN
_________________________________
Major
__________________________________________________
___________
GPA
Minor
□ Freshman
□ Sophomore
□ Junior
□ Senior
□ Graduate
□ Faculty/Staff
□ Other
1. On average, how many hours per week do you spend studying? ________________________________
2. As a result of any nutrition related health concerns have you:
•
Missed any classes within the past month?
Circle One
Yes / No
~If yes, how many? ________________
•
Performed poorly on class related tasks?
Yes
/ No
•
Failed an exam?
Yes
/ No
3. Do you have any nutrition-related health conditions for which you would like to
be referred to a Dietitian? (i.e.- diabetes, digestive disorders, etc.) If yes, please list:
Yes / No
Nutritional Analysis 3
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Nutritional Information
PLEASE COMPLETE IN PEN
3. What is your reason for completing the Nutritional Analysis? __________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. What nutritional goal(s) do you hope to reach as a result of the Nutritional Analysis?
_________________________________________________________________________________
_________________________________________________________________________________
If your goal(s) include weight change, what is your desired body weight? _________________________
5. Who prepares most of your meals? _____________________________________________________
6. How many times per week do you eat out? Exclude Dining Halls. ______________________________
Circle One
Yes / No
7. Are you a smoker?
8. Are you currently taking any prescription medications?
Yes / No
If so, please list and be specific: _______________________________________________________
_________________________________________________________________________________
9. Are you currently taking any non-prescription medications (i.e. supplements, vitamins, etc.)?
Yes / No
If so, please list and be specific: _______________________________________________________
_________________________________________________________________________________
10. Are you currently following any special diet(s)?
Yes / No
If so, please describe diet: ___________________________________________________________
_________________________________________________________________________________
11. Do you follow a vegetarian diet?
Yes / No
12. Do you feel your diet is nutritionally balanced?
Yes / No
13. Do you normally eat breakfast?
Yes / No
14. Who referred you for a nutrition analysis? Place an “X” in the box that applies.
□ Physician
□ Dietitian
□ Professor/Instructor
□ Self referral
□ Counselor/Mental Health Professional
□ Eating Disorder Team
□ Other:______________
15. Has anyone recommended you see a Dietitian or referred you to a Dietitian?
If yes, Name: ______________ Title: ______________ Relationship: __________
Yes /No
Nutritional Analysis 4
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Physical Activity
PLEASE COMPLETE IN PEN
15. What is your current physical activity level?
(Place an “X” in the box that best describes your daily activity level)

Sedentary:
o This activity level consists of the bare minimum; most time is spent at rest, lying down or sitting with
minimal movement (i.e.; watching TV, reading, studying…).

Lightly Active:
o This activity level includes most office workers, professionals, and students; daily activities consist of
approximately 8 hours of sleep and 16 hours awake, including 3 hours of light activity (i.e.; walking,
house chores, cooking…) and 1 hour of moderately intense activity (i.e.; running, rollerblading,
walking briskly…)

Active:
o This activity level includes most people who work in manual labor fields (i.e.; carpentry, construction,
or building trades) and/or those people who average 1 ½ - 2 hours of moderate exercise 3 or more
times per week (i.e.; elliptical machine, weight lifting, running…)

Very Active:
o This activity level includes most full-time athletes or others who are involved in very strenuous
activity on a daily basis.
16. If you checked that you are either lightly, moderately, or very active, please describe what types of activities you
engage in:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________
If you have any questions, feel free to contact the Nutrition Education Coordinator at 581-7786.
Nutritional Analysis 5
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Food Intake Information: Part 1
PLEASE COMPLETE IN PEN
Eating Attitudes Test Part A
Current Weight: ________
Highest Weight (excluding pregnancy): _______
Lowest Adult Weight: _______
Ideal Weight: _______
Eating Attitudes Test Part B
In the past 6 months have you:
Once a
Never month or
less
2-3
Once
times
a
a
week
month
2-6
times a
week
Once a
day or
more
A Gone on eating binges where you feel
that you may not be able to stop?
B
Ever made yourself sick (vomited) to
control your weight or shape?
C
Ever used laxatives, diet pills or diuretics
(water pills) to control your weight or
shape?
D Exercised more than 60 minutes a day to
lose or control your weight?
E
Lost 20 pounds or more in the past 6
months
Yes
No
EAT-26: Garner et al. 1982, Psychological Medicine, 12, 871-878. Adapted by D. Garner with permission.
Nutritional Analysis 6
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Part C: Please check a response for each of
the following statements:
Always
Usually
Often
Sometimes
Rarely
Never
1 I am terrified about being overweight.
2 I avoid eating when I am hungry.
3 I find myself preoccupied with food.
I have gone on eating binges where I
4 feel that I may not be able to stop.
5 I cut my food into small pieces.
I am aware of the calorie content of
6 foods that I eat.
7
I particularly avoid food with a high
carbohydrate content (i.e. bread, rice,
potatoes, etc.).
I feel that others would prefer if I ate
more.
8
9 I vomit after I have eaten.
10 I feel extremely guilty after eating.
I am preoccupied with a desire to be
11 thinner.
I think about burning up calories when I
12 exercise.
13 Other people think that I am too thin.
I am preoccupied with the thought of
14 having fat on my body.
I take longer than others to eat my
15 meals.
16
17
18
19
I avoid foods with sugar in them.
I eat diet foods.
I feel that food controls my life.
I display self-control around food.
20 I feel that others pressure me to eat.
21
22
23
24
25
26
I give too much time and thought to
food.
I feel uncomfortable after eating sweets.
I engage in dieting behavior.
I like my stomach to be empty.
I have the impulse to vomit after meals.
I enjoy trying new rich foods.
Nutritional Analysis 7
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
7 Ways to Size Up Your Servings
1
3 ounces of meat is about the size
and thickness of a deck of playing
cards.
=
2
A medium apple or peach is about
the size of a tennis ball.
3
1 ounce of cheese is about the size
of 4 stacked dice.
=
=
4
½ cup of ice cream is about the
size of a tennis ball.
5
1 cup of vegetables is about the size
of your fist.
6
7
=
=
1 teaspoon of butter or peanut
butter is about the size of the tip of
your thumb.
=
1 ounce of nuts or small candies
equals the palm of your hand.
=
Nutritional Analysis 8
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Standard Serving Sizes
**Below are the amounts that represent 1 serving from each food group**
Dairy
1 cup (8oz) Milk
1 cup Yogurt (size of baseball)
1 cup Soy Milk
1 ½ ounces of cheese (two 9-volt batteries)
Vegetables
½ cup cooked, chopped, or raw vegetables (small computer mouse)
1 cup raw, leafy greens
½ cup vegetable juice
Fruit
1 medium piece (size of baseball)
½ cup 100% fruit juice
½ cup chopped fresh or canned fruit
½ grapefruit or large banana
¼ cantaloupe
¼ cup dried fruit or raisins
Grains
½ bagel, hamburger bun, English muffin
1 cup cereal, cooked cereal (a baseball)
½ cup cooked pasta (size of palm of hand), cooked rice
1 slice of bread, tortilla shell, dinner roll
Meat, Meat Alternatives, & Beans
1 ounce of meat (usually eat 2-3 ounces at a sitting or the size of a deck of cards)
½ cup cooked dry beans, peas, or lentils
1 ounce cheese (one 9-volt battery)
2 tablespoons of peanut butter (golf ball)
1 large egg
1/3 cup nuts or seeds
Fat
1 teaspoon butter, mayonnaise, oil
1 tablespoon cream cheese, light whipping cream, half & half, regular salad dressing, reduced-fat
mayonnaise
2 tablespoons reduced-fat salad dressing
Nutritional Analysis 9
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
Food Intake Information: Part 2
PLEASE COMPLETE IN PEN
Please write the number of servings of each food group you consume daily. Refer to 7 Ways to Size up Your
Servings handout, Standard Serving Sizes handout, or contact the Nutrition Education Coordinator (581-7786)
if you have questions about serving sizes for each food group.
Food Group
Grains
Vegetables
Fruit
Dairy
Meat, Meat Substitutes, & Beans
Fats and Oils
Convenience Foods
Soda Pop & Sweetened Beverages
Number of Servings
Standard Residence Hall Serving Sizes
Chili, soups, stews
Rice, noodles, cooked cereal
Egg, tuna salad
Vegetables
Macaroni and cheese
Pancakes
1 cup
½ cup
1/3 cup
½ cup
¾ cup
2
Pasta dishes
Meat
Potatoes (mashed, au gratin)
French fries
Scrambled eggs
1 cup
3-4 ounces
¾ cup
15 fries
2 eggs
Convenience foods are foods that are prepackaged such as chips and candy bars. There are not standard
serving sizes for these foods. For these, indicate how many times a day you typically consume these types
of foods.
For soda pop and sweetened beverages, 12 ounces is a standard amount which is the size of a can of soda
pop. Remember, most soda pops come in larger containers. For these, indicate how many times a day
you typically consume these types of foods.
Nutritional Analysis 10
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
REMINDER
For 3-Day Food Intake Record, please record food intake for 2 weekdays and 1 weekend day (for example
Sunday, Monday, and Tuesday). This is because eating patterns tend to change during the weekends. Also,
please remember to record all beverage intake (including water) and amounts consumed, as well as any
condiments and seasonings. Remember, the more accurate your record is, the more accurate your nutritional
analysis results will be.
Food Intake Information: Part 3
PLEASE COMPLETE IN PEN
3-Day Food Record
In order to assist you in reaching your goals with respect to nutrient intake, it is important for us to know your
current eating patterns. Please use the attached forms to provide a detailed record of everything you eat and/or
drink over a three-day period. Try to record food and drink intake for Two Weekdays and One Weekend Day.
If your meals or snacks are from a restaurant, please provide the restaurant’s name and a detailed description of
what you ate in the Method of Preparation section. Feel free to attach any recipes, restaurant menus, or nutritional
value handouts to this form. Be as specific as possible when listing food and drink items, amounts, and any
additional ingredients (i.e. condiments, seasonings, or toppings). Do not try to change your eating habits during
the days of record keeping.
Refer to 7 Ways to Size up Your Servings for proper serving size information, or feel free to contact the
Nutrition Education Coordinator (581-7786) if you have any questions.
Daily Food Log Example:
Meal
Breakfast
Food Item
Oatmeal, instant apple cinnamon
Amount
1 packet
Method of Preparation
Prepared with water, added 1 tsp of butter
Activity Log Example:
Type of Exercise
Walking
Intensity
Moderate
Duration
20 minutes
Nutritional Analysis 11
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
DAY 1
The result of your 3-Day is only as accurate as your measurements.
Date: _________________
Amount
Food Item
(cups, pieces, oz…)
Method of Preparation
Breakfast:
Lunch:
Dinner:
Snacks:
Type of Exercise
Activity Log
Intensity
Duration
If you have any questions, feel free to contact the Nutrition Education Coordinator at 581-7786.
Nutritional Analysis 12
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
DAY 2
The result of your 3-Day is only as accurate as your measurements.
Date: _______________
Amount
Food Item
(cups, pieces, oz…)
Method of Preparation
Breakfast:
Lunch:
Dinner:
Snacks:
Type of Exercise
Activity Log
Intensity
Duration
If you have any questions, feel free to contact the Nutrition Education Coordinator at 581-7786.
Nutritional Analysis 13
Health Education Resource Center
5019 Student Services Building
600 Lincoln Ave.
Charleston, IL 61920
(217) 581-7786
DAY 3
The result of your 3-Day is only as accurate as your measurements.
Date: _______________
Amount
Food Item
(cups, pieces, oz…)
Method of Preparation
Breakfast:
Lunch:
Dinner:
Snacks:
Type of Exercise
Activity Log
Intensity
Duration
If you have any questions, feel free to contact the Nutrition Education Coordinator at 581-7786.
Nutritional Analysis 14