Factors Influencing Food Intake

Part I.
Yes

No

IBS attacks
and
symptoms

Items 1 through 20 check yes or no

1. Has a Good appetite
2. Resides Alone
3. Prepares Own Food
4. Has Cooking facilities
5. Has refrigeration
6. Has adequate funds for food
7. Shops in supermarket for food
8. Buys dietetic/Health foods
9. Follows 3 meal pattern daily
10.
Eats at normal pace
11.
Is a smoker
12.
Has food allergies
13.
Has food aversions
14.
Difficulty chewing
15.
Difficulty swallowing
16.
Constipation
17.
Diarrhea
18.
Nausea
19.
Vomiting
20.
Other GI complaints (If yes,
specify)

Part II.
Please check applicable items and note frequency when indicated
21.
Type of food preparation
_ Conventional Cooking
frequently cook
_ Convenience Foods
convenience food
_ Snack Foods
snack foods
22.
Location of meals
__Home
__Restaurant

Frequency
pt and husband
pt frequently eats
pt frequently consumes

about half of meals

about half of meals

__Other
23.

24.

_____________________

Food Cravings
____ Sweets
_____________________
____ Fried
____ Salty

_____________________
_____________________

Food preferences
____
Ethnic
_____________________
____ Religious
Fish on Fridays during

lent

Factors Influencing Food Intake

Use space below for additional information and for comments or
explanations about answers to questions 1-24. Reference number of the
question the comment relates to.

Pt does not always drink with meals, she carries a 16oz Arrowhead
water bottle and refills it through out the day
Pt is meticulous about keeping a food diary and trying to determine her
trigger foods

Factors Influencing Food Intake

Directions: Under usual pattern, record time, activities engaged in
throughout the day and while eating meals and snacks, and customary
eating patterns with portion sizes. Include all food, condiments, alcoholic and
carbonated beverages. Complete a full dietary analysis of the nutrient
content of the three-day diet recall.

Day 1
Hour

8am

12pm

2pm

5pm

Activity

Food Intake

None

(2100mL water
consumed throughout
the day)

None

None

None

Breakfast:
1 whole white English
muffin
2 tsp butter
2 tbs acacia fiber
8oz peppermint tea
Lunch:
McDonalds Filet-O-Fish
Small Fries
Snack 1:
cup sugar free
pudding
3 chessmen shortbread
cookies
Dinner:
Subway 6 tuna

8pm

None

sandwich
light mayo
lettuce/tomato
black olives
pickle
1 Bag Baked lays chips
Snack 2:
1 whole white English
muffin
1 tbs raspberry jam
8oz peppermint tea

Food Intake and Activity Patterns

Day 2
Hour

Activity

Food Intake
(2100mL water
consumed throughout
the day)

8am

None
Breakfast:
1 Eggo waffle
1 tsp butter
2 tbs Log Cabin Syrup
2 tbs acacia fiber

12pm

2pm

6pm

None

None

Lunch:
3oz Cheese Pizza
Fruit cup juice only
(peaches)

None

Snack 1:
1 Sugarless Popsicle
Dinner:
1 Cup Spaghetti
2oz Meat Sauce

1 Cup Green Salad

1 tbs Lite Ranch
Dressing
Dessert:
4 Mini Eclairs
2-8oz cups peppermint
tea

Food Intake and Activity Patterns

Day 3
Hour

Activity

Food Intake
(2100mL Water
consumed throughout
the day)

9am

None
Breakfast:
1 Packet Instant
Oatmeal (Plain)
1 tbs Skim Milk

1pm

None
Lunch:
1 Frozen Wanton Shrimp
Bowl
1 Sugarless Popsicle

5pm

None
Dinner:
4 oz Cod cooked in
1 tbs olive oil

1 Cup Mashed Potatoes

Can String Beans
8pm

None
Snack:
1 Bag Weight Watchers
Buttered Popcorn