Food Record Form □ Estimated □ Weighed

Name of Subject: Derrel Date of recording: 29th November 2020

Which day of the week is being recorded? □ Mon □ Tue □ Wed □ Thurs □ Fri □ Sat □ Sun
Is this your typical food intake? □ Yes □ No (explain: ____________________________________)

Description of food or drink, brand name, preparation

Place Eaten Time Amount eaten g / ml
method
Home 10.40am Water 1 glass 250ml

White bread 1 slice 35g

Sliced ham 1 slice 15 g

Home 2.30pm 1/2 plate 150g

White Rice
Fried chicken wing 2 pieces 400g

Home 8pm White rice 1 bowl 300g

Kang Kong ½ plate 200g

Chicken nuggets 4 pieces 64g