3 Day Food Journal

It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Journal for 3 consecutive days including one weekend day.

  • Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
  • Record information as soon as possilble after the food has been consumed.
  • Describe the food or beverage as accurately as possible e.g. milk – what kind: 2%, whole, notfat, etc.; toast -whole wheat, white, buttered, etc.; chicken – fried, baked, breaded, etc.; coffee -decaffeinated with sugar and half and half, etc.
  • Record the amount of each food or beverage consumed using the standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
  • Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
  • Record all beverages, including water, coffee, tea, sports drinks, sodas / diet sodas, etc.
  • Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc.)
  • Please note all bowel movements and their consistency (regular, loose, firm, etc.)

3 Day Food Journal

Please follow the instructions noted above to complete your 3 day food journal.
  • Include Date/Time, Food/Beverage/Amount and any additional Comments
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  • Include Date/Time, Food/Beverage/Amount and any additional Comments
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  • (#, form, color)
  • Include Date/Time, Food/Beverage/Amount and any additional Comments
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  • This field is for validation purposes and should be left unchanged.