Free HealthCheck Adolescent's Food Record, HCF 01066B - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1066B (07/08)

STATE OF WISCONSIN

HEALTHCHECK ADOLESCENT'S FOOD RECORD (13 TO 20 Years of Age)

Name of Adolescent

Date

Directions: Write down everything you had to eat or drink and how much in the last 24 hours (meals and snacks). Start with the first time you ate yesterday to the first time you ate today. Example
10:30 AM Noon Home Home Donut, 4 ounces apple juice Sandwich ­ 2 slices whole wheat bread, 2 slices cheddar cheese, 1 tablespoon butter 1 cup (8 ounces) tomato soup made with 2% milk AMOUNT AND FOOD OR BEVERAGE CONSUMED

TIME

PLACE

OFFICE USE ONLY

Bread

Vegetables

Fruit

Milk

Meat

1. Is this the way you eat most of the time?

Yes

No

If no, why not? _______________________________________

2. What foods do you refuse to eat? _________________________________________________________________________________

3. How often do you eat away from home? 1 to 2 times a week 2 to 4 times a week Almost every day Where are these meals eaten? __________________________________________ 4. Are you on a diet, following diet restrictions or trying to control your weight? Yes No

5. How many times in the last month did you have problems getting enough food? _________________________________