UAMS Medical Center Feature
Calorie Reporting Form / Diary of Daily Food Intake
Print this page and make copies to use this as a dietary assessment and calorie reporting form.
Please speak to your doctor or nutritionist to determine the best plan for you.

Date: ____________________________

What did you eat? Example: 2 eggs	How much did you eat? Example: 2 fluid oz., 1 cup, 1 biscuit	When did you eat? Example: 7:15 a.m., 12:15 p.m., 6:15 p.m.	Number of Calories
Breakfast





Lunch






Dinner






Snacks





Total Calories Check this box when you make your number! __________

For more information and to schedule an appointment for a free orientation, call (501) 603-1497, (501) 686-7911 or the UAMS Access Number at (501) 686-8000.
Or Contact us at weight@exchange.uams.edu

Back to UAMS Medical Center Weight Program Story