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Description

Current Supplement Use
Baseline Question: Are you taking any supplements? This includes all over–‐ the–‐ counter and prescribed
supplements (e.g. multivitamin, iron, fish oil, etc.). Yes No
If yes, please list all supplements in the table below.
All Follow–‐ Up Visits: Have you had any changes to your supplements since your last visit? Yes No
If yes, please indicate in the table below which supplements you have started or stopped taking, or if the
dose or frequency has changed for any current supplements.
Name of Supplement
Dose
Frequency
Start Date
Stop Date

Reason for Taking Supplement
e.g. Vitamin D
1000 IU
1x / day
Oct. 2010
Bone health
(osteoporosis)
Fish oil
4grams
1×/day
Sept. 2012
Dec 2012
Reduce inflammation
magnesium
350gm
1×/day
Nov. 2010
Dec 2010
Bone health
probiotic
1 billion
CFUs
1×/day
Feb. 2012
April. 2012 Indigestion, bloating, and diarrhea
Calcium
1000 gm Per day
Oct. 2010

Bone health
Sample 1–‐ Day Food Record
Below is an EXAMPLE of how to keep accurate records. Include a detailed description and amounts for each
item. Remember to record water, notes on product details, and the times of day you ate.
TIME
AMOUNT
DESCRIPTION
NOTES
8am
Large
1 Tbsp
2 tsp
Coffee
Cream
Sugar
Tim Horton’s
Sour fat free
White sugar
11am
2 slices
2 oz.
1 Tbsp
1 leaf
1 tsp
Bread, whole wheat
Turkey, lunchmeat
Mayo (Hellman’s)
Romaine Lettuce
Becel Margarine
Slice, thin
Oven–‐ roasted from deli
“light”, 4.5g fat per Tbsp
raw
11:30pm
2 cups
Water, tap
Carbonated tonic
2pm
1 medium
Apply (granny smith)
97 cals (with skin)
6
Whole wheat crackers (Premium Plus)
1”x1” cube
Marble cheese, 35%MF
80 cals, 2.5g fat, 210mg
sodium (from label)
Crackerbarrel
4pm
1 large
500mL
Muffin, blueberry
Water, tap
Store–‐ bought
Store- bought
7:30pm
1 patty
1
1 leaf
2 slices
1 slice
2 Tbsp
1 bottle
Hamburger, BBQ’d (regular ground beef)
Hamburger Bun, white bread
Iceburg Lettuce
Tomato, raw
Red Onion, raw
Ketchup, Heinz
Beer (12 oz, 5% alcohol)
M&M Meat Shops (~4oz.)
120 cals ( rolls)
8 cal/cup (chopped)
54 cals ( red tomatoes)
64 cals / cup
2 cups
Chocolate ice cream
10pm
Salt–‐ free
45 calories per tsp
Moosehead
Chapman’s
Was this a typical day? If not, why? Usually drink more water (forgot water bottle at home)
Did you take all of your usual medications and supplements as prescribed? 
Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
TIME
8:00 a.m.
AMOUNT
DESCRIPTION
4grams
I take fish oil to help reduce inflammation.
The supplement is taken once in a day.
1 billion CFUs day.
NOTES
Omega-3 fatty acids help in
preventing diseases including
inflammation.
I take probiotic to reduce
indigestion and bloat.
10:00
11:00
12: 00
I cup
1cookie
1 serving
Coffee black
Chocolate chip cookies
380 cals
No sugar
67 cals
Hot dog
2: 00p.m.
1 cup
Tomato soup
1 cup210 cals
8: 30 noon
Probiotics: The supplement is taken once in a
4: 00 p.m. Package yield Package yield Chicken noodle soup
chicken
253 cals
6:00 p.m.
One serving
1 cup
Caesar salad homemade
Rice white cooked without salt
250 cals
242 cals
8: 00 p.m.
1 tbsp salad
Salad dressing coleslaw
63 cals
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
TIME
8:00 a.m.
AMOUNT
DESCRIPTION
1 container
Greek Yogurt low fat
1 cup
tea
Vitamin D
20 mcg of Vitamin D is consumed in a day for
treating bone diseases.
NOTES
146 cals
No sugar (2cals)
I take this supplement to
improve bone health
10: 00 a.m. crackers
316 cals
Cup, bite, size
12: 00
noon
I sandwich
250 cals
2: 00 p.m. Apple with
skin raw
Medium, about 2.5 diameter
72 cals
4: 00 p.m. 1 serving
salad
Garden salad
160 cals
6: 00 p.m. I serving of
salmon
Grilled salmon
210 cals
8: 00p.m
Carrot baby raw
4 cals
Turkey &
cheese
sandwich
I medium
carrot
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
TIME
8:00 p.m.
AMOUNT
DESCRIPTION
1 cup milk
Milk reduced fat 2% milkfat
122 cals
1 large egg
Egg scrambled
91 cals
10: 00 a.m. 1 cup juice
Orange juice
112 cals
11:00 p.m. 21gms
Fibers: The supplement is taken once in a day. I take fibers to reduce
constipation and indigestion.
Grilled chicken sandwich with lettuce tomato 419 cals
mayo
Pepperoni pizza
305 cals
12: 00 p.m. Sandwich
NOTES
2:00 p.m.
1 slice pizza
4:00 p.m.
Medium
banana
Banana raw
105 cals
6:00 p.m.
1 serving
spaghetti
Spaghetti served with meatballs
293 cals
8:00 p.m.
1 cup coffee
Coffee black no sugar
2 cals
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No
DAILY FOOD RECORD
Subject Code:
Date
Weekday or Weekend
Please list all food/beverages/water/medications/supplements. Estimate all food/drink amounts accurately.
Was this a typical day? If not, why?
Did you take all of your usual medications and supplements as prescribed? Yes No

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