Introduction
Patient's Name _________________
Date ______________
1: Food Groups
| |
Grains
(bread, cereal, rice & pasta) |
Vegetables |
Fruits |
Dairy |
Meat
or Meat Alternatives |
|
| Recommended Daily Amounts: |
6-8oz. |
2-3 cups |
1 1/2-2 cups |
3 cups |
5-6 1/2oz. |
| Daily Amounts You Eat: |
___ |
___ |
___ |
___ |
___ |
| Additional Amounts Needed: |
___ |
___ |
___ |
___ |
___ | |
2: Fats, Oils & Sweets
Recommended: Use sparingly
Amount you eat: ______________________________
3: Beverages
Recommended: Beverages should provide fluids and nutrients without excessive calories.
Current beverage choices that may be a problem: ______________________________
4: Prescription
Your suggested dietary changes are checked below:
- ____ Eat more breads, cereals, rice and pasta.
- ____ Eat more vegetables.
- ____ Eat more fruits.
- ____ Drink more milk, and eat more yogurt and cheese.
- ____ Eat more meat, poultry, fish, dry beans, eggs and nuts.
- ____ Eat more low-fat meats, milk, yogurt and cheese.
- ____ Eat fewer meats, eggs, nuts and dry beans and less poultry and fish.
- ____ Eat fewer eggs (no more than 4 whole eggs or yolks per week).
- ____ Eat fewer fats, oils and sweets.
- ____ Drink fewer sweetened beverages.
- ____ Drink less alcohol.
- ____ Eat less salt and fewer high-sodium foods.
- ____ Drink no- or low-calorie beverages, such as water, unsweetened tea or diet soda pop.
Other prescriptions:
Physician's Signature ______________________________ Date ______________
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