Food Journal/Dietary History

Patient's Name

Date of Birth

Are you following a special diet? Yes or No, 
explain

Check any of the following that apply

How many meals eaten away from home (include how often)

Skipping Meals (include how often)

Food preferences

Food dislikes

Who plans your meals?

Who does the grocery shopping?

Who does the cooking?

Beverages - What beverages do you regularly consume? In what quantity? How often? Example - 2c/d; every weekend, etc.

Alcohol

Coffee

Fruit Juice

Milk

Soda

Tea

Water

Other(s)

What are your best food habits?

What are your worst food habits?

Please download and complete your Food Diary HERE

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