Daily Food Diary Sample
ADVERTISEMENT
1DAILY FOOD
DIARY-SAMPLE
Weight
Fatigue
Shortness of
# of Pillows
BP
HR
Blood
Urine Output
Exercise / Other Activity
Breath
under head
sugar
Yes
No
Yes
Increased
Yes
No
154.4
No
2
98/54
78
134
Decreased
Walked 10 minutes on
Same
treadmill
BREAKFAST
SODIUM MG
FLUID OZ
LUNCH
SODIUM MG
FLUID OZ
DINNER
SODIUM MG
FLUID OZ
COFFEE
0
7 OZ
CRANBERRY JUICE
35 MG
8 OZ
GRAPE JUICE
15 MG
8 OZ
10 MG
8 OZ
SWEET POTATO
53 MG
TURKEY SOUP
125 MG
8 OZ
APPLE JUICE
0 MG
ROASTED CHICKEN
105 MG
UNSALTED TOP
75 MG
OATMEAL
(DARK MEAT)
CRACKERS
105 MG
CABBAGE
14 MG
STRAWBERRY SALAD
65 MG
TOAST (WHITE)
SEASONING
0 MG
W/STRAWBERRY
1 SLICE
VINAGRETTE
122 MG
½ CUP COTTAGE
360 MG
SNACK COOKIES
50 MG
½ CUP MILK
CHEESE
0 MG
PEACHES
0 MG
BLUEBERRIES
2 SCRAMBLED EGGS
110 MG
GRAPES
0 MG
6 CHIPS
45 MG
BLACKBERRIES
0 MG
GRAPE JUICE
15 MG
8 OZ
WATER WITH PILLS
10 OZ
BLUEBERRIES
0 MG
COFFEE
7 OZ
347 MG
25 OZ
567 MG
8 OZ
390 MG
31 OZ
TOTAL
Your Goal Is
2,000 cc (64 ounces) per 24 hour fluid restriction met Yes No -64 ounces
2,000 mg per 24 hour sodium restriction met
Yes No -1304 mg
Other
Yes No
:___________________________________________________
COMMENTS ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Miscellaneous