Food Intake Form

Date: _________

Indicate the number of servings that each food represents.
Food/beverage Amount Milk, Yogurt, Cheese Group Meat, Poultry, Fish, Dry Beans, Eggs & Nuts Group Fruit Group Vegetable Group Bread, Cereal, Rice & Pasta Group Fats & Sweets Hunger Level* Mood**
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
*Hunger level: 0 = not hungry; 3 = very hungry
**Mood: 1 = good/happy; 2 = fair; 3 = upset

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