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| Food Diary |
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| Intake Record For Nutritional Analysis |
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| An important aspects of a nutritional assessment is an analysis of your food and beverage intake. Please fill in the following form and fax or e-mail it two days before your appointment. The data will be analyzed on a nutritional analysis software program. The print-out will show an average of your intake of protein, fat, carbohydrate, fibre, vitamins and minerals and will compare them to your recommended intake. |
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| Please record all of the food or drink taken over a period of three days. To provide an |
| accurate portrayal of your eating patterns try to include two working days and one day off. Include all beverages and extra food items such as water, toppings, condiments, margarine, butter or mayonnaise. Record any supplements or vitamins/minerals that you may take. At the bottom of each page indicate the amount of physical activity you had each day. You may use the extra column to the right to record feelings of hunger, physical activity or other test results. |
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| ___________________________________________________________ |
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| Date: __________________ |
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| Name:______________________Ht:_______Wt:____________ |
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| Sex:____________Age:____________ |
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| Time Meal Food or Drink Taken Activity |
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| _____Breakfast |
| Starch |
| Fruit/Veg |
| Milk |
| Protein |
| Fats |
| Sugars |
| _____ Snack |
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| _________________________________________________________ _____ Lunch |
| Starch |
| Fruit/Veg |
| Milk |
| Protein |
| Fats |
| Free Veg |
| Sugars |
| ____ Snack |
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| __________________________________________________________ _____ Dinner |
| Starch |
| Fruit/Veg |
| Milk |
| Protein |
| Fats |
| Free Veg |
| Sugars |
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| _____Snack |
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| Exercise Time and Duration____________________________________ Water,Total Intake in cups or litres _____________________________ |
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