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Name:

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3-Day Food Record Day

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Height:

h*

C?nl

DayofWeek:

Date:

Weight:

140

MT

(circle one)

Activity Level*:

1-

O,

sa

su

*Activity level:
1. Sedentary: Very inactivz, sometimes under the care of another peraon. 2. Lightly Active: Most office workers and professionals.
Eguals 8 hours of sleep, 16 hours of sittinglstanding of which 3 hours ls light (e.9. walking, laundry) and t hour of moderate {e.g. tennis, bisk walk,
aercbics) activity. 3. Moderately Aetive: Most persons in light industry, building trades, child carc prcviders, active students (approximately 1.*2
hours of moderate activity per day). 4. Very Active: Full time athletes, mine or steel workers, army recruits, 5. Extremety Active: Lumberjacks, active
construction workera, heavy manual digging, coal miners.

Please record as accurately as possible all food and beverages you consumed for one day. Please give as many
details as possible regarding the food/beverage item. Please list all supplements consumed including sports
foods/beverages, vitamins, minerals, herbs etc. When eating out specify the restaurant and when you use
convenience foods please specify the brands.

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3-Day Food Record Day 2

Date;

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DayofWeek:

MT

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*Activity level: 1. Sedentary: Very

inactive, sometimes under the care of another Wrson. 2. Lightty Active: Most offtce wotkers and professionats.
Eguals 8 hours of sleep, 16 hours of sitting/standing of which 3 hours is light (e.g. walking, laundry) and t hour of moderate (e.g. tennis, bisk watk,
aerobics) activity. 3. Moderately Active: Most persons in light industry, building trades, child care providers, active students (approximatety 1.*2
hours of moderate activity per day). 4. Very Ac,tive: Full time athletes, mine or steet wotkers, army recruits. 5. Extremely Adiie: Lumbe4acks, active
construction workers, heavy manual digging, coal miners.

Please record as accurately as possible all food and beverages you consumed for one day'. Please give as many
details as possible regarding the foodibeverage item. Please list all supplements consumed including sports
foods/beverages, vitamins, minerals, herbs etc. When eating out specify the restaurant and when you use
convenience foods please specify the brands.

Time

Food/Beverage

Brand or Source

Type ol Preparation

8:00 am

Example: cinnamon raisin bagel

Lenders

Toasted

9:00

Example: weighttraining

moderate lntensity

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3-Day Food Record O"VX

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oate:

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-Activity level: 1. Sedentary: Very inactive, somefmes under the

care of another person. 2. Lightly Active: Most offtce workers and prcfessrbnals.
Equals t hours of sleep, 16 hours of siftingy'standing of which 3 hoars is light (e.9. walking, Iaundry) and t hour of moderate (e.g. tennis, bisk walk,
aerobics) activity. 3. Moderately Active: Most persons in light industry, building trades, child carc providers, active students (approximately 1.*2
hours of moderate activi| per day). 4. Very Active: Full time athletes, mine or steel workers, army recruits. 5. Extremely Active: Lumberjacks, active
construction workers, heavy manual digging, coal miners.

Please record as accurately as possible all food and beverages you consumed for one day. Please give as many
details as possible regarding the food/beverage item. Please list all supplements consumed including sports
foods/beverages, vitamins, minerals, herbs etc. When eating out specify the restaurant and when you use
convenience foods please specify the brands.

Time
8:00 am
9:00

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FoodlBeverage

Example: cinnamon raisin

Example: weighttraining
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Brand or Source
bagel

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Amount

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Type of Preparation

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