Diet Assignment - Sample and Blank Form
The next page is a Sample Food Record Form for you to look at to get a better idea of what a food record looks like. (you
do not need to turn this in! Just look at it carefully). Refer to the assignment instructions on My Learning Web for
details on how to fill this out
Print at least 3 copies of the blank form which follows the Sample (for Days 1, 2 and 3). You can hand-write what you ate
directly onto these sheets (use pen, not pencil, and write clearly). If you wish, you can download the pages onto your
computer and fill them in on the computer, printing them when you are done and ready to turn them in.
I have set the margins, all of them, at .5”. If you do so, your sheets will each fill 1 page and not roll over to the next. (go
to File on the menu above, select Page Setup and click on “Margins”.) Also, it is best if you select the page orientation as
“Landscape” (go to File, then Page Setup, then Paper Source and select “Landscape”.) You can print additional copies of
the forms if you need more than 1 page for each day.
Food Record
Food & Beverages
SAMPLE
orange juice with Calcium and Vit. D
L
Fried eggs
Portion/
Quantity
Time
Hunger/Emotio
n/why I ate
Where food
from
1 cup
8 am
4 / tired
H
1 pm
5 / stressed
H-C
2
Butter (fried eggs in it)
L
½ tsp.
100% whole wheat bread
L
2 slices
Margarine: “I can’t Believe it’s not butter, light”
L
2 tsp.
Cantaloupe
½ of whole
Turkey Sandwich:
White bread
L
2 slices
Turkey breast – deli sliced
L
2 ounces (wt)
Mayonnaise, light
L
1 TB
Lettuce
½ lg leaf
Coke
L
1 can
M and M s
L
1 bag-2.1oz
2 pm
0 – bored
Ice Cream (Baskin Robbins), chocolate, on sugar cone
CW
Small scoop
4 pm
0 – happy
R
Chicken Whopper
CW
1 whole
7 pm
4 - tired
FF - BK
French fries
CW
Large order
Raisin bran cereal
L
2 cups
1% low fat milk
L
1 cup
Pepperoni pizza
CW
1 large slice
FF - BK
10 pm -
3 – just feel
like having a
snack
H - TV
midnight
0 – roommate
FF – Pizza
Hut - TV
came home with it,
smelled good!
Food Record
Day 1, 2, or 3
(circle day)
Use pen, not pencil. Print. Write neatly so it is legible. Write 1 food per line.
Food & Beverages
Name ________________________
Class ______
_______
___
Date ______________________ ___
Portion/
Quantity
Time
Hunger/Emotion
/ Why I ate
Where food
from