TIME / MEAL WHERE EATEN NAME OF FOOD METHOD OF QUANTITY Double check all

OR DRINK COOKING/INGREDIENTS CONSUMED/CHECK intakes.

OTHER
INGREDIENTS

BREAKFAST
- - - - -
Time: _______

AM SNACKS HOME
Yema - 3 pieces -
Time: 10 AM

LUNCH HOME Rice Steamed 2 cups

-
Time: 1 PM Pork Adobo Simmered 1 cup

PM SNACKS HOME
Donut Baked - -
Time: 3 PM

DINNER HOME Rice Steamed 2 cups

-
Time: 8 PM Liempo Grilled 1 slice

MIDNIGHT SNACKS HOME

Spanish Bread Baked 2 pieces -
Time: 12 AM

24-HR FOOD RECALL

1. How many glasses or ml of water (pure form excluding other beverages) have you drunk on the day of the recall?
8 glasses
___________________________________________________________________________________________
2. Did you take in supplements or medicine on the day of the recall? YES ______________ NO
3. Is your consumption for this day representative of your usual food intake? YES NO
If your answer is NO, please explain briefly in the space provided below:

_________________________________________________________________________________________________________