Clinical Hub,Patient Education,Health and Nutrition Facts For You,Nutrition

Digestive Health: Food Record (473)

Digestive Health: Food Record (473) - Clinical Hub, Patient Education, Health and Nutrition Facts For You, Nutrition


Patient Name:________________________ Birth Date: __________ Clinic: _________________

Food Record of Everything You Ate or Drank
Write the name and amount of all food or drinks. Include brand names. Don’t
forget extras like butter, salad dressings, sauces and gravy. Indicate how
prepared, for example baked or fried. Give measurable amounts, such as
1 teaspoon, 1 Tablespoon, 4 ounces, ½ cup or 1 saltine cracker
Stooling Pattern
Record type and when stool occurs. Can
add comments about pain, gas, or any
description of a problem.

Food and Amount Time Diarrhea Soft Hard Other






Please record any medicines, vitamins, and herbal supplements used:___________________________________________


Please return completed form to:________________________________________________________________________

If you are a UW Health patient and have more questions please contact UW Health at one of the phone numbers listed below. You
can also visit our website at www.uwhealth.org/nutrition. Nutrition clinics for UW Hospital and Clinics (UWHC) and American
Family Children’s Hospital (AFCH) can be reached at: (608) 890-5500. Nutrition clinics for UW Medical Foundation (UWMF) can
be reached at: (608) 287-2770.

Copyright 03/2015. University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Clinical Nutrition Services Department and
the Department of Nursing. HF#473