Detailed Daily Food Intake Record
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3Detailed Food Intake Record
Name: ________________________________________________________________________
Reference Record #: ____________________________________________________________
Tel: (Home) ________________________
(Mobile) ___________________________________
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Date of Birth: ____________________________
Gender:
Male
Female
Breakfast
Place
Time
Food/Beverage
Describe how prepared; additional ingredients
Amount
Yogurt/other dairy
Fruit
•
fresh
•
canned
•
other
Cereal
•
cold/dry
•
oatmeal, grits
•
with milk
Bread
•
butter or substitute
•
jam
•
white or whole grain
Meat
Eggs
Beverage
•
coffee
•
juice
•
milk
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Parent category: Miscellaneous