Women's Health Initiative

Transcription

1 Women's Health Initiative Form - Four-Day Food Record Ver.. Name of participant: For the period of: Day (such as Friday): Date (such as September, ): If you have questions, call: at: Next Appointment Date: Time: Place: R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

2 General Instructions For Keeping Record Please use black ink and write clearly. Record each meal/snack right after it is eaten. Fill in the Meal and Place Prepared sections for each meal or snack. In the Place Prepared column, write H for foods prepared at Home, R for foods prepared in a Restaurant, and O for foods prepared in Other places. Write each food or ingredient on a separate line. Skip a line after each meal or snack. If more space is needed for the same day, use the next page. Start each new day on a new page. Use the recipe pages starting on page to describe homemade recipes. See sample on page. Use additional pages if needed and staple them to the food record. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

3 Instructions For Recording Foods and Beverages Please keep the following things in mind when you write down the foods you eat. See sample on pages,, and. Fully describe foods, beverages, sauces, spreads, etc. Example: chicken thigh, skin not eaten; French dressing, low calorie. Write down brand names if you know them. Explain how foods are prepared. Example: Is meat fried, broiled, baked, breaded, etc.? For foods prepared with fat, write down the kind of fat used. Example: fried in margarine (list brand name). Include foods you add at the table. Write these down on a separate line. Example: baked potato with TB (tablespoon) butter List each food or ingredient used in sandwiches and mixed dishes. Record exact amounts. Measure all foods in cups, tsp (teaspoons), TB (Tablespoons), or size in inches. If you have any questions, call your study contact person. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

4 Vitamin and Mineral Supplements Did you take a multivitamin during the days you kept this record? Yes No If Yes, check the type(s) you used: One-a-day type multivitamins with minerals, such as Centrum, or Theragran with Beta-Carotene without Beta-Carotene (look on the label) One-a-day type multivitamins without minerals with Beta-Carotene without Beta-Carotene (look on the label) Stress type multivitamins such as Stresstabs with Beta-Carotene without Beta-Carotene (look on the label) Antioxidant mixture such as Protegra Did you take any vitamins or minerals as a separate pill? Yes No Dose per pill Vitamin C Vitamin E Vitamin A/Beta-Carotene Beta-Carotene Calcium Iron mg. IU IU IU mg. mg. Do you take a fiber supplement such as Metamucil or Citrucel? If yes, Name: R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

5 Please write these vitamins and minerals in your daily food record when you take them. I:\FORMS\NUTRN\Fv_.DOC /0/ Pg. of Printing () Draft : 0//

6 General Questions What brands and types of foods did you use while keeping this record? Milk: whole % % skim Margarine: stick tub squeeze regular diet/low fat fat free Brand Name: Salad Dressings: regular diet/low fat fat free Type (Such as French, Italian, Ranch): Brand Name: Oil: Type (Such as Corn, Canola, Soybean): Brand Name: Mayonnaise: regular light/reduced calorie fat free cholesterol free/reduced calorie cholesterol free Brand Name: R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

7 PARTICIPANT ID# - - Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Sunday Date: // S A M P L E Foods And Beverages Amount B H Orange Juice, unsweetened / cup Oatmeal, quick cooking made with water / cup Margarine, Mazola, stick tsp % milk / cup Brown Sugar tsp Coffee, decaffeinated cups Cream, half and half TB Toast, whole wheat slice Margarine, Mazola, stick tsp Multivitamin pill Vitamin C pill R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

8 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

9 PARTICIPANT ID# - - Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Sunday Date: // S A M P L E Foods And Beverages Amount L H Sandwich: Whole Wheat Bread slices Ham, boiled, deli ("L x "W x /th) slice Cheese, American Processed (/ oz/slice) slices Best Foods Mayonnaise TB Potato chips, ripple type oz bag Diet Coke with caffeine can Nabisco Oreo Cookies D H Beef Stew (see recipe page ) serving Salad: Lettuce, romaine cup R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

10 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

11 PARTICIPANT ID# - - Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Sunday Date: // SAMPLE Foods And Beverages Amount Tomato, peeled / med Cucumber, sliced " piece Hidden Valley Ranch dressing, regular TB Roll, white, yeast "W x "L x "th Butter tsp S H Chocolate Ice Cream, Dryer's Grand / cup R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

12 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

13 PARTICIPANT ID# - - Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

14 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

15 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

16 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

17 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks PARTICIPANT ID# - - Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

18 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

19 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks PARTICIPANT ID# - - Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

20 Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. 0 of

21 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

22 R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

23 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

24 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

25 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

26 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

27 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

28 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

29 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

30 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. 0 of

31 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

32 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

33 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

34 Place Prepared H = Home R = Restaurant O = Other Meal B = B'fast L = Lunch D = Dinner S = Snacks Day: Date: / / Foods And Beverages Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

35 PARTICIPANT ID# - - Do Not Write On This Page For Clinic Use Only Was Fat Added at the Table? Was Fat Added in Preparation? Enter a N = No Y = Yes or U = Unknown for each column. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

36 Sample Recipe: Beef Stew Number of servings recipe made: Number of servings you ate: Name Ingredients Amount Stew beef, boneless chuck roast, trimmed lbs browned in Crisco Shortening / cup white flour TB onion, chopped large beef broth, canned cup tomato sauce, canned cup dry red wine / cup potatoes, medium sized, white, peeled, cut in half carrots (about " long), sliced celery, chopped cup fresh parsley, chopped / cup Simmer - hours R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

37 PARTICIPANT ID# - - Recipe Number of servings recipe made: Number of servings you ate: Name Ingredients Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

38 Recipe Number of servings recipe made: Number of servings you ate: Name Ingredients Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

39 PARTICIPANT ID# - - Recipe Number of servings recipe made: Number of servings you ate: Name Ingredients Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

40 Recipe Number of servings recipe made: Number of servings you ate: Name Ingredients Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. 0 of

41 PARTICIPANT ID# - - Recipe Number of servings recipe made: Number of servings you ate: Name Ingredients Amount R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of

42 WHI Form - Four-Day Food Record Ver.. R:\DOCUMENT\FORMS\FV-.DOC 0// Pg. of