Note: Complete one form for each of three days (preferably 2 weekdays and 1 weekend day). Bring the completed
forms to the Nutrition Office (Room 119) in Student Health at least 2 working days before your appointment.
Questions? Call: (858) 822-0085.
Daily Food Intake: Please list everything you eat, include all snacks and beverages. Be sure to include the serving
size, like cups, ounces, # of pieces, etc… Complete each column (TIME, FOOD, AMOUNT, HUNGER/MOOD). This
should represent a typical day's food intake. If a certain day was not a typical day, you may select a more typical day.
Be honest with your daily diet so that we can provide you with an accurate assessment.