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 Changes in appetiteTaste or smell changesChewing/swallowing difficultiesEmotional eating 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? Δ Please download and complete your Food Diary HERE
