Complete for Initial Nutrition Appointment

Diet Recall Form

Complete for initial nutrition appointment

Instructions

·  Keep track of everything you eat and drink for three days. Be sure to include meals, snacks and beverages.

·  Record how the items are prepared—i.e. baked, fried, broiled, etc.

·  Record the approximate serving size—i.e. ½ cup, 1 cup, 3 ounces, etc. (Use the Helpful Hints chart below). Serving amount is very important for an accurate report!

·  If you know brand names, please include that information. If you ate out, include where you ate.

·  The most accurate way to keep food journals is to record your intake as soon after eating as possible.

·  Try to include two weekdays and one weekend day. Often the two days are different and we want to average them.

·  If you made a dish at home, at the bottom of the daily form, indicate what major ingredients were used. e.g. Lasagna: ground beef, marinara sauce, and cheese. Or, Stir-fry: chicken thigh meat, variety of veggies, olive and sesame oils and hoisin sauce.

Portion Control Size Guide

This Amount = Size of:

3 ounces meat deck of cards

1/2 cup golf ball

1 cup tennis ball

1 teaspoon tip of thumb

1 tablespoon whole thumb

For questions, please contact:

Linda Adams RD (530) 752-6800

Your information:

Name: ______Age: ______

Gender: Male____ Female ____ Pregnant Female ____ Nursing Female ____

Activity Level (circle one):

Sedentary: Light activities without additional exercise. This level includes sitting quietly, riding in a car, walking from the house to the car or bus, household tasks, and light yard work. Sedentary activity level = basal energy expenditure + thermic effect of food + sedentary activities.

Lightly Active: Sedentary activities plus 1-1.5 hours per day of additional activity, such as walking 2 mph, playing a musical instrument, leisure canoeing, ballroom dancing, golf (with cart), horseback riding (walking), and playing pool.

Moderately Active: Sedentary activities plus 1-2 hours per day of additional activity, such as calisthenics (no weight), cycling (leisurely), golf (without cart), swimming (slow), and walking 3-4 mph.

Very Active: Sedentary activities plus 1-2 hours per day of additional activity such as chopping wood, climbing hills, cycling, aerobic dancing, rope skipping, skating, skiing, squash, surfing, swimming, tennis, and running 5 mph (12 minute mile).

Height: ______ft ______in Weight: ______lbs

E-mail: ______Birth Date: ______

Goals (i.e. weight loss, weight gain, maintenance):______

If your goal is weight gain/loss, how many pounds do you plan to lose or gain a week?

(more than 2lbs/week is not recommended) ______lbs.

NOTE: Each daily tracking sheet is followed by an exercise log. You can indicate any particular exercise you did that day. This will create a more accurate estimate of energy needs.

Dietary Analysis – FOOD/EXERCISE JOURNAL

Name:______ / Date: ______Day # ______of ____
FOOD JOURNAL
Meal # or Type / Time / Name of Food Item (including brand) / Number of Servings/ Amount
Recipes
Recipe Item: / Recipe Item:
Ingredients (including approx. amount of each in one serving) / Ingredients (including approx. amount of each in one serving)
Name: ______ / Date: ______Day # ______of _____
EXERCISE JOURNAL
Name of Exercise / Time of Exercise / Intensity(low, moderate, vigorous) / Duration
Mood/Comments:
Name:______ / Date: ______Day # ______of _____
FOOD JOURNAL
Meal # or Type / Time / Name of Food Item (including brand) / Number of Servings/ Amount
Recipes
Recipe Item: / Recipe Item:
Ingredients (including approx. amount of each in one serving) / Ingredients (including approx. amount of each in one serving)
Name: ______ / Date: ______Day # ______of ____
EXERCISE JOURNAL
Name of Exercise / Time of Exercise / Intensity(low, moderate, vigorous) / Duration
Mood/Comments:
Name:______ / Date: ______Day # ______of _____
FOOD JOURNAL
Meal # or Type / Time / Name of Food Item (including brand) / Number of Servings/ Amount
Recipes
Recipe Item: / Recipe Item:
Ingredients (including approx. amount of each in one serving) / Ingredients (including approx. amount of each in one serving)
Name: ______ / Date: ______Day # ______of ____
EXERCISE JOURNAL
Name of Exercise / Time of Exercise / Intensity(low, moderate, vigorous) / Duration
Mood/Comments:

After completing the form, email or fax to Linda at fax: 530.752.5277.

We will discuss the results at your initial Work Strong nutrition appointment.

Rev. 4.13.2017