Healthy Eating/Wellness: Food Record
Clinic: ______________________
Patient Name: __________________________
Date of Birth: ________________
Food Record 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. |
Stooling Pattern Record type and when stool occurs |
Food |
Amount |
Diarrhea |
Soft |
Hard |
Other |
Breakfast
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Snack
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Lunch
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Snack
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Dinner
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Snack
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Please record any medicines /vitamins/herbal supplements
used:
________________________________________________
Please return completed form to:______________________
The Spanish version of this food record is #474.
The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.
Last Updated: 08/14/2012
Copyright © 05/21/2012 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#473
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