Form F-01066b - Healthcheck Adolescent'S Food Record (13 To 20 Years Of Age)

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01066B (07/08)
HEALTHCHECK ADOLESCENT’S FOOD RECORD
(13 TO 20 Years of Age)
Name of Adolescent
Date
Directions: Write down everything you had to eat or drink and how much in the last 24 hours (meals and snacks). Start with
the first time you ate yesterday to the first time you ate today.
E
xample
10:30 AM
Home
Donut, 4 ounces apple juice
Noon
Home
Sandwich – 2 slices whole wheat bread, 2 slices cheddar cheese, 1 tablespoon
butter
1 cup (8 ounces) tomato soup made with 2% milk
TIME
PLACE
AMOUNT AND FOOD OR BEVERAGE CONSUMED
Bread
Vegetables
Fruit
Milk
Meat
OFFICE USE ONLY
1. Is this the way you eat most of the time?
Yes
No
If no, why not? _______________________________________
2. What foods do you refuse to eat? _________________________________________________________________________________
3. How often do you eat away from home?
1 to 2 times a week
2 to 4 times a week
Almost every day
Where are these meals eaten? __________________________________________
4. Are you on a diet, following diet restrictions or trying to control your weight?
Yes
No
5. How many times in the last month did you have problems getting enough food? _________________________________
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