Food

TOTALS
Recommendations
NAME:

DAY ONE

0
3-5 Vegetable Servings

0
6-11 Breakfast and Cereal Servings

0
2-4 Fruit Servings
Diet Assessment

0
2-3 Dairy Servings

0
2-3 Meats and Protein Servings

0
See note * Calories (kcals)

0
See note † Protein (gm)

0
>58% of diet Carbohydrate (g)

0
30% of diet Fiber (g)

0
<30% of diet Fat (g)

0
From food label Total Fat % (kcal)

0
<10% of diet Saturated Fat (g)

0
<300mg Cholesterol (mg)
DATE:

0
3000 mg Sodium (mg)

0
700-900 ug Vitamin A (ug)

0
65-90 mg Vitamin C (mg)

0
See note ‡ Calcium (mg)

0
See note § Iron (mg)
 Food

TOTALS
Recommendations
DAY TWO

0
3-5 Vegetable Servings

0
6-11 Breakfast and Cereal Servings

0
2-4 Fruit Servings

0
2-3 Dairy Servings

0
2-3 Meats and Protein Servings

0
See note * Calories (kcals)

0
See note † Protein (gm)

0
>58% of diet Carbohydrate (g)

0
30% of diet Fiber (g)

0
<30% of diet Fat (g)

0
From food label Total Fat % (kcal)

0
<10% of diet Saturated Fat (g)

0
<300mg Cholesterol (mg)

0
3000 mg Sodium (mg)

0
700-900 ug Vitamin A (ug)

0
65-90 mg Vitamin C (mg)

0
See note ‡ Calcium (mg)

0
See note § Iron (mg)
 Food

TOTALS
Recommendations
DAY THREE

0
3-5 Vegetable Servings

0
6-11 Breakfast and Cereal Servings

0
2-4 Fruit Servings

0
2-3 Dairy Servings

0
2-3 Meats and Protein Servings

0
See note * Calories (kcals)

0
See note † Protein (gm)

0
>58% of diet Carbohydrate (g)

0
30% of diet Fiber (g)

0
<30% of diet Fat (g)

0
From food label Total Fat % (kcal)

0
<10% of diet Saturated Fat (g)

0
<300mg Cholesterol (mg)

0
3000 mg Sodium (mg)

0
700-900 ug Vitamin A (ug)

0
65-90 mg Vitamin C (mg)

0
See note ‡ Calcium (mg)

0
See note § Iron (mg)