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Queensland Health Dietitian/ Nutritionist Patient Label
DO NOT FILE:
RETAIN FOR DIETITIAN
Food and Fluid Consumption Chart
Day & Date: ____________________________
Breakfast Please record name of food/drink (please circle)
Comment Pro kJ
Cereal None ¼ ½ ¾ All
Milk None ¼ ½ ¾ All
Yoghurt None ¼ ½ ¾ All
Hot breakfast None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Morning Tea Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Lunch Please record name of food/drink
Soup None ¼ ½ ¾ All
Meat/protein None ¼ ½ ¾ All
Potato/rice None ¼ ½ ¾ All
Vegies/salad None ¼ ½ ¾ All
Sandwich None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Dessert None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Afternoon Tea Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Dinner Please record name of food/drink
Soup None ¼ ½ ¾ All
Meat/protein None ¼ ½ ¾ All
Potato/rice None ¼ ½ ¾ All
Vegies/salad None ¼ ½ ¾ All
Sandwich None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Dessert None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Supper Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Tea/coffee/other None ¼ ½ ¾ All
Food items in bold are high protein/energy – encourage intake
Start date: _______________ Finish date: ________________ Commenced by: ________________________
This is a consensus document from Dietitian/ Nutritionists from the Nutrition Education Materials Online, "NEMO", team.
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp Reviewed: May 2017
Due for Review: May 2019
Queensland Health Dietitian/ Nutritionists Patient Label
DO NOT FILE:
RETAIN FOR DIETITIAN
Food and Fluid Consumption Chart
Day & Date: ____________________________
Breakfast Please record name of food/drink (please circle)
Comment Pro kJ
Cereal None ¼ ½ ¾ All
Milk None ¼ ½ ¾ All
Yoghurt None ¼ ½ ¾ All
Hot breakfast None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Morning Tea Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Lunch Please record name of food/drink
Soup None ¼ ½ ¾ All
Meat/protein None ¼ ½ ¾ All
Potato/rice None ¼ ½ ¾ All
Vegies/salad None ¼ ½ ¾ All
Sandwich None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Dessert None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Afternoon Tea Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Dinner Please record name of food/drink
Soup None ¼ ½ ¾ All
Meat/protein None ¼ ½ ¾ All
Potato/rice None ¼ ½ ¾ All
Vegies/salad None ¼ ½ ¾ All
Sandwich None ¼ ½ ¾ All
Bread None ¼ ½ ¾ All
Fruit None ¼ ½ ¾ All
Dessert None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Juice/tea/coffee None ¼ ½ ¾ All
Supper Please record name of food/drink
Snack None ¼ ½ ¾ All
Supplement None ¼ ½ ¾ All
Tea/coffee/other None ¼ ½ ¾ All
Food items in bold are high protein/energy – encourage intake
Start date: _______________ Finish date: ________________ Commenced by: ________________________
This is a consensus document from Dietitian/ Nutritionists from the Nutrition Education Materials Online, "NEMO", team.
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp Reviewed: May 2017
Due for Review: May 2019
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