Poor eating habits can lead to several medical problems. The three risk factors related to diet and cardiovascular disease are elevated blood fats, hypertension, and obesity. It will be helpful for both you and your dietitian to assess what you are eating in order to make desirable changes.

Fill out the records as completely as possible, including all food and beverages at each meal and all snacks. Do not forget to include sauces and dressings when added to a meal. Please do not change your eating habits for the purpose of this record!

Below is a sample of how you should fill out the form:

Meal 6
Time of Day: 6:00pm

Item, Quantity, Prep Method/ Brand
Dinner Salad, 1 cup, tossed salad
Salad Dressing, 1 Tbls., oil & vinegar
Fish (salmon), 8 oz., fried
Rice, 1/2 cup, boiled minute rice
Corn, 1/3 cup, canned Green Giant
Coffee, 2 cups, cream & 2 tsp. sugar
Chocolate Cake, 1 sm. slice, home-made Betty Crocker


Full Name:
Email Address:


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