Nutrition Prescription

Patient's Name _______________

Date __________

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 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.

Other prescriptions:




Physician's Signature _____________________ Date ____________