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

Healthy Eating/Wellness: Daily Food Diary (606)

Healthy Eating/Wellness: Daily Food Diary (606) - Clinical Hub, Patient Education, Health and Nutrition Facts For You, Nutrition

606

Food Group Daily Servings Serving Size Examples Check All That Apply
Grains and
Starchy
Vegetables
0–1 2–3 3–4
More
than 4
1 slice of bread
1/2 cup cooked oatmeal
1/2 English muffin
1/3 cup cooked rice
1/4 cup cooked pasta
Bread, bagels, tortillas, rice, pasta, cold or cooked
cereals, potatoes, peas, corn
Percentage I eat that are whole grains:
0% Less than 50% More than 50%
I consume sweetened
drinks such as juice,
tea, soda, sport drinks
3 or more times per
week.
I consume alcoholic
drinks.
Type:
Volume:
Frequency:
I eat at or take out
from restaurants,
fast food chains,
cafeterias or delis
more than 3 meals
per week.
I add salt to my food
at the table, cook with
salt and/or consume
salty snacks (such
as chips, crackers,
pretzels, snack mixes)
on a regular basis.
Vegetables
0–1 2–3 3–4
More
than 4
1 cup leafy or raw vegetables
1/2 cup cooked vegetables
6 oz. low sodium vegetable juice
Brussels sprouts, green beans, carrots, zucchini,
tomatoes, broccoli, bell peppers, cauliflower,
leafy greens
Fruit
0–1 2–3 3–4
More
than 4
1 medium fruit
1/2 banana
15 grapes
1/4 cup dried fruit
1/2 cup fresh or frozen fruit
Berries, melon, apples, oranges, grapefruit,
bananas, raisins, peaches, pears, plums,
pineapple, mango, prunes, kiwi
Dairy
0-1 2-3
More
than 3
8 oz. (1 cup) milk
1 cup yogurt
1/2 cup cottage cheese
1 oz. cheese
Milk, regular or Greek yogurt, cheeses, cream,
sour cream
Meat, Poultry
and Fish
0 1–2 3–4
More
than 4
1 serving is 3 oz. cooked meat,
roughly the size of a deck of cards
Beef, pork, poultry, fish, bacon, sausage, hotdogs,
brats, salami
Fats and Oils
0-1 2-3 4-5
More
than 5
1 tsp. tub margarine or butter
1 Tbsp. mayonnaise
2 Tbsp. salad dressing
1/4 avocado
Oils used in cooking and baking, butter, margarine,
olives, avocado
For cooking/baking, I use: Butter/Margarine
Canola Oil Olive Oil Vegetable Oil
Other
Vegetarian Proteins
0-1
2 or
more
1/4 cup nuts
2 Tbsp. seeds
1/2 cup cooked beans
1/2 cup tofu
1 egg
Nuts, peanuts, sunflower seeds, pumpkin seeds,
flaxseed, chia seeds, lentils, beans, chickpeas
(garbanzo beans), tofu, veggie burgers, eggs
Sweets
None 1
2 or
more
1 Tbsp. sugar, jelly, jam or honey
1/2 cup frozen yogurt or ice cream
1–2 small cookies
1 oz. chocolate
Muffins, pastries, donuts, cookies, frozen desserts,
candy or candy bars
Prior to your appointment, please fill out this form. Use the serving sizes and examples
provided to guide your selections. This tool will help the dietitian offer you personalized
recommendations during your visit. If you have additional comments or questions, please
bring them on a separate sheet of paper.
WHAT DO YOU
TYPICALLY EAT?
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Meal Food/Beverages Portion
(cup, tsp., oz., etc.)
Hunger Level 0–5
0=Not 5=Very
Location Reason For Eating
Breakfast
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Snack
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Lunch
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Snack
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Dinner
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Snack
Time: _________
Home Work
Out to eat In the car
Other


Hungry Bored
Socializing Emotional
Other


Physical Activity: None 15 minutes 30 minutes 45 minutes 60 minutes or more
Before your appointment, please pick one weekday to record what you
eat and drink, as well as your physical activity for the day. Remember,
this is not a test! Knowing how you currently eat will help your care team
provide personalized recommendations to optimize your heart health.
DAILY FOOD DIARY
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