Three-Day Food Record
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1 Three-Day Food Record Please keep this Food Record three days before your next: Study visit / Filter paper Start (Month # )
2 Three-Day Food Record Instructions We will ask you to keep a three-day food record: Three days before each study visit, and Three days before taking a blood sample for each filter paper card Please record everything you actually eat and drink for three days in a row Weigh and/or measure your food before you eat it Subtract any amount that you did not eat and record your actual intake on the food record To estimate portion sizes, use the instructions in this packet, measuring spoons and cups, a ruler, and a scale Record what you eat and drink as soon as you can to reduce the chance of forgetting Write only one food or drink item per line Estimate the amount of phenylalanine (Phe) in milligrams or exchanges for the serving of food or drink that you actually ate (15 mg of Phe equals 1 Phe exchange) Double-check your food record. Did you remember to write down: All meals, snacks, nibbling, and beverages including cocktails? Recipes? Ingredients used in mixed dishes, sandwiches, etc.? Seasonings, spices, or condiments added to foods? Whether weights are for cooked or raw portions? How the food was prepared (uncooked vs. cooked) Specify how the food was cooked: baked, boiled, broiled, fried, grilled, steamed, toasted If the food is a specialty low protein item? Whether there was ice in any beverages? If you have any questions about your food record, please call Sarah at or Dr. Singh at
3 A Handy Way to Estimate Portion Size Part of Hand Portion Size Examples of Foods Whole Fist 1 cup 2 servings of vegetables, 1 piece of fruit Palm of Hand 1 oz 1 serving of snack chips or pretzels Finger Length 2.5 inches Diameter of 1 fruit serving or 1 tennis ball Whole Thumb 2 Tbsp, 20 ml, 1 fl oz, 1 oz, 28 g 1 serving of low protein peanut butter or cheese Thumb Tip 1 tsp, 5 ml 1 serving of margarine 2
4 Ways to Describe Portion Size Description Measuring cups (C), teaspoons (t or tsp), tablespoons (T or Tbsp) Examples Vegetables, canned or frozen fruits, pasta, casseroles, all liquids such as water, beverages, soups, sauces, salad dressings, sorbet, or smoothies. Fluid Ounces (fl oz) All liquids such as water, beverages, soups, sauces, salad dressings, sorbet, or smoothies. Weight in grams (g) or ounces (oz) Any solid food such as low protein cheese, frozen entrees, or dry medical food powder (formula). Fraction of the whole 1/8 of 9" pie or 1/4 of 6" cantaloupe. Diameter (D) Any sphere, such as a 3" diameter apple, roll, or tomato. Diameter and Thickness Any cylinder or disk, such as a pancake, cracker, cookie, or low protein burger (eg: a 3" diameter, 1/2" thick low protein burger patty). Length and Height and Width Any rectangle or square such as a 3" long, 3" high, 2" wide piece of chocolate cake or low protein bread. Length and Height and Width of Arc Any wedge, such as a slice of low protein pizza or pie. 3
5 Food Record: DAY 1, Page 1 Participant Day of Week: F M L Friday March / 0 7 / Medical Food (Phe-free formula) Other Ingredients Volume Product Name Amount Other Ingredients Brand Name Amount Mixed 1 Phenex g Strawberry Syrup Hershey s 1 T 24 fl oz Volume Consumed 19 fl oz Water 2 Amino Acid Blend 26 g Lemonade Mix Country Time 3/8 cap (51 g) 24 fl oz 50% Water 3 # of servings per day: 2 Please circle: Did you take the SAME, MORE, or LESS medical food (Phe-free formula) than usual? Medication Name Advil 200 mg Ibuprofen per tablet Medications Vitamins, Minerals, or Other Supplements Brand Name Total Amount Taken Supplement Name Brand Name Total Amount Wyeth 1 Tablet Calcium 500 mg tabs & Vitamin D CVS 1 Tablet Please continue on the reverse side if you need more space. 4
6 Time / Meal* Participant Initials: F M L March / 0 7 / Food Record: DAY 1, Page 2 Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe 8A/B Low-Pro Cereal Loops 1 cup H Loprofin 2 0 B Rich s Coffee Rich ½ cup H Rich s 16 1 B Sugar 1 T H Domino 0 0 B Banana 1 (medium) H A/SN Fresh Cantaloupe, Cubed ¾ cup O P/L Low Protein Burger (Camburger) 1 Fried Canola Oil O L Low-Pro LBP Burger Bun 1 roll Toasted --- O Cambrooke (oil: Wesson) Dietary Specialties L Romaine Lettuce 1 outer leaf O L Red Tomato (Beefsteak) 1 slice (1/4 diameter) O L Ketchup 1 T O Hunt s L Baby Carrots 1 cup O L Regular Potato Chips 1 oz O Lay s L Coke 12 fl. oz O Coca-Cola 0 0 2P/SN Green Apple, Granny Smith 1 medium O SN Low Protein Peanut Butter 2 T O Dietary Specialties 8 1 6P/D Low-Pro Spaghetti 1.5 cups (cooked) Boiled Butter H Loprofin (butter: Cabot) 23 2 D Spaghetti Sauce (Traditional) ¼ cup Simmered --- H Prego 24 2 * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Total (page 2): 26 Ex 5
7 Time / Meal* Participant Initials: F M L March / 0 7 / Food Record: DAY 1, Page 3 Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe D Low-Protein Bread 1 slice Toasted --- H Cambrooke 15 1 D Soft Margarine 1 T H Promise P/SN Fresh Strawberries ½ cup H * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 3): 34 mg 2.5 Ex Please circle: Did you eat the SAME, MORE, or LESS food than usual? Total (page 2 + page 3): 379 mg 28.5 Ex Please describe anything that affected your diet while keeping today s food record. Forgot formula at home this morning. Drank as much as I could when I got home today, but got too full to drink all of it. Please continue on the reverse side if you need more space. 6
8 Recipes Participant Initials: F M L Month/Year: March / Month Year Recipe 1: Low-protein spaghetti Recipe 2: 2 oz Dry Low-Pro Spaghetti (Loprofin) 4 cups Water 1 Tbsp Butter (Cabot salted butter) 1 tsp Salt Boiled for 10 minutes. Recipe 3: Recipe 4: 7
9 1 Food Record: DAY, Page 1 Medical Food (Phe-free formula) Other Ingredients Product Name Amount Other Ingredients Brand Name Amount Participant Initials: Day of Week: / / Volume Mixed Volume Consumed 2 3 # of servings per day: Please circle: Did you take the SAME, MORE, or LESS medical food (Phe-free formula) than usual? Medication Name Medications Vitamins, Minerals, or Other Supplements Brand Name Total Amount Taken Supplement Name Brand Name Total Amount Please continue on the reverse side if you need more space. 8
10 Participant Initials: / / Food Record: DAY, Page 2 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 2): mg Ex 9
11 Participant Initials: / / Food Record: DAY, Page 3 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 3): mg Ex Please circle: Did you eat the SAME, MORE, or LESS food than usual? Total (page 2 + page 3): mg Ex Please describe anything that affected your diet while keeping today s food record. Please continue on the reverse side if you need more space. 10
12 1 Food Record: DAY, Page 1 Medical Food (Phe-free formula) Other Ingredients Product Name Amount Other Ingredients Brand Name Amount Participant Initials: Day of Week: / / Volume Mixed Volume Consumed 2 3 # of servings per day: Please circle: Did you take the SAME, MORE, or LESS medical food (Phe-free formula) than usual? Medication Name Medications Vitamins, Minerals, or Other Supplements Brand Name Total Amount Taken Supplement Name Brand Name Total Amount Please continue on the reverse side if you need more space. 11
13 Participant Initials: / / Food Record: DAY, Page 2 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 2): 12 mg Ex
14 Participant Initials: / / Food Record: DAY, Page 3 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 3): mg Ex Please circle: Did you eat the SAME, MORE, or LESS food than usual? Total (page 2 + page 3): mg Ex Please describe anything that affected your diet while keeping today s food record. Please continue on the reverse side if you need more space. 13
15 1 Food Record: DAY, Page 1 Medical Food (Phe-free formula) Other Ingredients Product Name Amount Other Ingredients Brand Name Amount Participant Initials: Day of Week: / / Volume Mixed Volume Consumed 2 3 # of servings per day: Please circle: Did you take the SAME, MORE, or LESS medical food (Phe-free formula) than usual? Medication Name Medications Vitamins, Minerals, or Other Supplements Brand Name Total Amount Taken Supplement Name Brand Name Total Amount Please continue on the reverse side if you need more space. 14
16 Participant Initials: / / Food Record: DAY, Page 2 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 2): mg Ex 15
17 Participant Initials: / / Food Record: DAY, Page 3 Time / Meal* Food Item Be specific. Only one item per line! Write low-pro if a specialty low protein item Amount Specify oz, tsp, etc. Cooking method Type of fat used when cooking Where eaten? H (home) R (restaurant) O (other) Brand / Restaurant Phe (mg) Exchanges 1 exchange = 15 mg Phe * Meal: B=Breakfast; L=Lunch; D=Dinner; SN=Snack Subtotal (page 3): mg Ex Please circle: Did you eat the SAME, MORE, or LESS food than usual? Total (page 2 + page 3): mg Ex Please describe anything that affected your diet while keeping today s food record. Please continue on the reverse side if you need more space. 16
18 Recipes Participant Initials: Month/Year: / Month Year Recipe 1: Recipe 2: Recipe 3: Recipe 4: 17
19 Recipes Participant Initials: Month/Year: / Month Year Recipe 5: Recipe 6: Recipe 7: Recipe 8: 18
Please record everything you actually eat and drink for three days in a row.
1 Three Day Food Record Instructions We will ask you to keep a 3 day food record: o Three days before each study visit, and o Three days before taking a blood sample for each filter paper card Please record
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