Pediatric Service Intake Form

On the following pages you will find a three day food and activity record. Record everything you r child eats/drinks for three days in a row. It is preferable to have some weekdays as well as weekends.

The food record will be used to complete a detailed nutrition assessment of your intake. Please try to be as accurate as possible so that you can receive the most relevant advice.

The following information is needed:

• Type and amount of food consumed

  e.g., 3 oz. (deck of cards) boneless, skinless baked chicken breast

  e.g., 1 cup (1 fist) or 250 ml or 8 oz. of skim milk

• Method of food preparation

  e.g., baked in the oven with no fat

  e.g., pan fried in 2 teaspoons of olive oil

• Brand names of commercial products

  e.g., 1 cup Campbell’s Cream of Chicken soup made with 1 % milk

  e.g., 1 large Wendy’s Chili

• Condiments added to foods

  e.g., 1 tablespoon natural peanut butter

  e.g., 1 teaspoon butter