Form Dhcs - 4466 - What Do You Eat - Sheet printable pdf download

What do you eat?

State of California—Health and Human Services Agency

Department of Health Care Services

For office use only

What did you eat yesterday? List everything you ate and drank. How much? What time?

Time

Amount

Food or Drink

(Check (�) topics discussed)

10:00 a.m.

½ cup

Carrots

� �� Continue eating healthy

� ��

regular meals/snacks

� �

Encourage breakfast

�

Inadequate food supply

� �

Encourage lower fat

� �� Encourage lower sugar

�� Weight management

�� Disordered eating

�Was yesterday a typical day? _____Yes _____No

�

Other________________

Circle the foods you eat often.

Iron/Protein

pizza

�

seafood

� �� 2 - 3 servings daily

cereal

tofu

� ��

ham/pork

bread

high iron foods�

�

potato

dried fruit

� ��

alternate protein sources �

hot dog

� � � for vegetarian diets

chicken/turkey

� ��

beans, lentils, peas

beans,

hamburger

spaghetti

dark leafy

peas,

� �� Limit high fat meats

taco

bacon/sausage

egg

greens

beef

lentils

Fruits and Vegetables

vegetable

Fruits and Vegetables

carrots

apple

soup

tomato

pepper

� �� 2 - 4 Fruits daily or more

corn

100%

potato

� �� 3 - 5 Vegetables daily or more�

juice

salad

cantaloupe

� �� Vitamin C sources

� �� Vitamin A sources

zucchini

orange/

banana

dark leafy

grapefruit

grapes

peas/green beans

broccoli

greens

Calcium

whole

milk

pizza

calcium

nonfat/lowfat

� �� 3 - 4 servings daily

tofu

cottage cheese

� �� Encourage nonfat or

nonfat or

lactose

corn

1% milk

� � � 1% milk

free

tortillas

� ��

high fat choices

milk

calcium

2% milk

� ��

low lactose alternatives

frozen

fortified

� ��

nonfat/

yogurt/

calcium-fortified foods

100%

ice milk

broccoli

lowfat

juice

cheese

ice cream

yogurt

milkshake

Snacks

donuts/sweet rolls

Snacks

bagel/bread

pretzels

� ��

high sugar snacks

crackers

� ��

high fat snacks

� ��

fruit/vegetable snacks

air-popped

candy

fruit pies

�

��

�

chips

french fries

movie popcorn

fruits & vegetables

fast food

popcorn

Drinks

iced tea

�

Drinks

flavored

100%

drink

juice

� �� Limit juice: 1/day

� � � (4-8 oz. total)

� �� Drink 100% juice

� �� Drink 8-12 glasses �

�

� � � water/day

(8 oz. each)

wine/

fruit

�� Discourage fruit drinks

water

wine

�

drink

� �� Discourage soda/caffeine

cooler

diet soda

beer

soda

sports drink

� �� Discourage alcohol

coffee

milk

Name_________________________________Age_______________Date of Birth__________________Date_______________

Don't Stop!

Please turn me over. . .

DHCS 4466 (09/07)

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Form Dhcs - 4466 - What Do You Eat - Sheet

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