Patient's Name _______________
1: Food Groups
Recommended Daily Amounts
|Daily Amounts You Eat||Additional Amounts Needed
|Grains (bread, cereal, rice & pasta)
||3-6 oz. whole grains|
||2 1/2 cup|
|Meat or Meat Alternatives||5-6 1/2 oz.|
2: Fats, Oils & Sweets
Recommended: Use sparingly
Amount you eat: ______________________________
Recommended: Beverages should provide fluids and nutrients without excessive calories.
Current beverage choices that may be a problem: ______________________________
Your suggested dietary changes are checked below:
____ Eat more whole-grain breads, cereals, rice and pasta.
____ Eat more vegetables.
____ Eat more fruits.
____ Drink more milk, and eat more yogurt and cheese.
____ Eat more meat, poultry, fish, dry beans, eggs and nuts.
____ Eat more low-fat meats, milk, yogurt and cheese.
____ Eat fewer meats, eggs, nuts and dry beans and less poultry and fish.
____ Eat fewer eggs (no more than 4 whole eggs or yolks per week).
____ Eat fewer fats, oils and sweets.
____ Drink fewer sweetened beverages.
____ Drink less alcohol.
____ Eat less salt and fewer high-sodium foods.
____ Drink no- or low-calorie beverages, such as water, unsweetened tea or diet soda pop.
Physician's Signature _____________________
Some information adapted from Physicians Guide to Outpatient Nutrition, by Sylvia A. Moore, Ph.D., R.D., F.A.D.A. and John P. Nagle, M.P.A. American Academy of Family Physicians, Leawood, KS. 2001.
Written by familydoctor.org editorial staff