Please list the foods that you typically eat for each meal.  Make sure to include foods that are not eaten frequently. 
Please underline the foods that are eaten more frequently.  For example, if you eat cereal almost every day for breakfast, but only have eggs once a week, then underline the cereal and make sure to include the eggs on the list.

 

 

Breakfast:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Lunch:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Dinner:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________

 

 

Snack:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Dessert:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

For each food class, please indicate how often you eat it. 
Write down whatever is most appropriate, be it once a day, 4 times a week, 3 times a day, etc….

 

 

Meat (beef, chicken, steak, turkey, ham, pork, luncheon meats, burgers): ________________________________

 

 

Dairy (milk, cheese, yogurt, ice cream):___________________________________ Eggs: __________________

 

 

Bread: ________________________ Beans: ______________________ Fruit: ___________________________

 

 

Fish (including tuna): _________________ Salads: ___________________ Vegetables: ___________________

 

 

Nuts and seeds (including peanut butter): ____________________________ Rice: ________________________

 

 

Sweets (cookies, candy, cake, ice cream, etc.): ________________________ Cereal: _____________________

 

 

Pasta: _________________________________________  Soy or  Tofu: ________________________________

 

 

For the liquids, please list how many 8 ounce cups per day or week.

 

 

Water: ____________________________ Juice: _________________________ Milk: _____________________

 

 

Coffee (regular or decaf): _________________________  Tea/Herbal Tea _______________________________

 

 

Alcohol: ______________________ Soda: ____________________ Other: ______________________________