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4-Day Food Record
OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 60 minutes for
this questionnaire, including the time to review instructions, search existing data sources,
gather and maintain the data needed, and complete and review the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a current, valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge
Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA (####-####).
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General Instructions
Please eat as you usually eat.
Record everything you eat and drink (except water), including
snacks.
Complete the Meal and Place Prepared columns for each meal or
snack.
Start each new day on a new page.
Please write clearly.
How to Record Each Food
Describe each food and beverage in detail, as best you can.
Include:
For example:
How prepared
(fried, grilled, breaded, etc.)
Added fats
(fried in butter)
Brand name
(Stouffer’s Frozen Lasagna)
Portion size
(½ cup, 4 oz., 1 x 3 x 2 cube)
Describe each ingredient in a mixed dish:
- Chicken
3 cups Romaine, 1 medium chicken
Caesar Salad
breast (no skin) grilled, ¼ cup caesar
dressing, 2 Tbsp. Parmesan cheese,
6 large croutons
- Spaghetti &
1½ cups cooked spaghetti, 4 meatballs
Meat Balls
(1 diameter), ½ cup Ragu meatless
spaghetti sauce, 1 Tbsp. Parmesan cheese
For help with portion sizes, use “Five Ways to Size up Your
Servings” (page 3), the ruler at the back of this booklet, and the
enclosed Serving Size Booklet.
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© National Dairy Council
2/24/2004
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General Questions
Please check ( ) below.
Usually /
Always
Sometimes
Yes
No
Rarely /
Never
1. When you eat bread or rolls, how
often do you add butter or
margarine?
2. When you cook vegetables, how
often do you add oil, margarine or
butter?
3. When you eat vegetables, how
often do you add oil, butter or
margarine at the table?
4. When you eat potatoes, how often
do you use butter, margarine, or
sour cream?
5. How often do you use milk or
cream in coffee or tea?
6. When you eat chicken or turkey,
how often do you eat the skin?
7. Do you eat in restaurants or
purchase take-out food more than
three times per week?
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What type of milk, spreads and cooking oils do you usually use?
Please specify only the type you use most often.
Please check ( ) below.
1. Milk (include all types – regular cow
milk, acidophilus, and soy milk):
4. Salad Dressing:
Whole
Regular
2%
Diet/low fat
1%
Fat free
Skim
Didn’t use
Didn’t use
5. Oil:
2. Margarine:
Regular
Canola oil
Diet/low fat
Corn oil
Fat free
Olive oil
Spray
Safflower oil
Didn’t use
Soybean oil
Other oil
Didn’t use
3. Real Butter:
6. Mayonnaise:
Regular
Regular
Light
Low fat
Didn’t use
Fat free
Didn’t use
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EXAMPLE
Place Prepared
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Saturday
Foods And Beverages
2/24/2004
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Date: 08 / 03 / 02
Amount
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EXAMPLE
Place Prepared
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Saturday
Foods And Beverages
2/24/2004
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Date: 08 / 03 / 02
Amount
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Place Prepared
DAY 1
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 1
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
2/24/2004
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Place Prepared
DAY 1
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 2
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
=
B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 2
H = Home
R = Restaurant
O = Other
Meal
B
L
D
S
=
=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 2
H = Home
R = Restaurant
O = Other
Meal
B
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D
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=
=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 3
H = Home
R = Restaurant
O = Other
Meal
B
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=
=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 3
H = Home
R = Restaurant
O = Other
Meal
B
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=
=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 3
H = Home
R = Restaurant
O = Other
Meal
B
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=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 4
H = Home
R = Restaurant
O = Other
Meal
B
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=
=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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Place Prepared
DAY 4
H = Home
R = Restaurant
O = Other
Meal
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B'fast
Lunch
Dinner
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Day:
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Foods And Beverages
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Place Prepared
DAY 4
H = Home
R = Restaurant
O = Other
Meal
B
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=
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B'fast
Lunch
Dinner
Snacks
Day:
Date: ____/____/____
Foods And Beverages
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THANK YOU!
© Fred Hutchinson Cancer Research Center
2/24/2004
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| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |