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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