Food And Fluid Consumption Chart - Queensland Health
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2Queensland Health Dietitian/ Nutritionists
Patient Label
DO NOT FILE:
RETAIN FOR DIETITIAN
Food and Fluid Consumption Chart
Day & Date: ____________________________
Breakfast
Please record name of food/drink
(please circle)
Comment
Pro
kJ
Cereal
None
¼
½
¾
All
Milk
None
¼
½
¾
All
Yoghurt
None
¼
½
¾
All
Hot breakfast
None
¼
½
¾
All
Bread
None
¼
½
¾
All
Fruit
None
¼
½
¾
All
Juice/tea/coffee
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Morning Tea Please record name of food/drink
Snack
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Juice/tea/coffee
None
¼
½
¾
All
Lunch
Please record name of food/drink
Soup
None
¼
½
¾
All
Meat/protein
None
¼
½
¾
All
Potato/rice
None
¼
½
¾
All
Vegies/salad
None
¼
½
¾
All
Sandwich
None
¼
½
¾
All
Bread
None
¼
½
¾
All
Fruit
None
¼
½
¾
All
Dessert
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Juice/tea/coffee
None
¼
½
¾
All
Afternoon Tea Please record name of food/drink
Snack
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Juice/tea/coffee
None
¼
½
¾
All
Dinner
Please record name of food/drink
Soup
None
¼
½
¾
All
None
¼
½
¾
All
Meat/protein
Potato/rice
None
¼
½
¾
All
Vegies/salad
None
¼
½
¾
All
Sandwich
None
¼
½
¾
All
Bread
None
¼
½
¾
All
Fruit
None
¼
½
¾
All
Dessert
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Juice/tea/coffee
None
¼
½
¾
All
Supper
Please record name of food/drink
Snack
None
¼
½
¾
All
Supplement
None
¼
½
¾
All
Tea/coffee/other
None
¼
½
¾
All
Food items in bold are high protein/energy – encourage intake
Start date: _______________
Finish date: ________________ Commenced by: ________________________
This is a consensus document from Dietitian/ Nutritionists from the Nutrition Education Materials Online, "NEMO", team.
Disclaimer:
Reviewed: May 2015
Due for Review: May 2017
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