03 SFM CO Applicant 24-Hour Diet Recall

Please complete the following for a 24-hour period. You can add food/beverages to the chart below. Use the "Save" button to recieve an email and downloadable link to keep the entered information and complete the form at another time.

Date*

Date

Applicant Name*

First NameMiddle Name or InitialLast Name

Date of Birth*

Date

Email*

example@example.com

Pregnant?*

YesNo

Nursing?*

YesNo

Activity Level per Day:*

Less than 30 minutes30-60 minutesMore than 60 minutes

Amount spent on food last month:*

List what you had to eat and drink in the last 24 hours. Be thorough. List one food/beverage per line. Click "Save and Add Row" after each item. *

Use these abbreviations to complete your 24-hour diet recall.

	Meal Time Abbreviations		Serving Abbreviations
	Morning = 1		Tablespoon = TBSP
	Mid-Morning = 2		Cup = c
	Noon = 3		Teaspoon = tsp
	Afternoon = 4		Pound = lb
	Evening = 5		Ounce = oz
	Late Evening = 6		Slice = sl

How many alcoholic beverages do you consume per week?*

How many caffeinated beverages do you consume per day?*

How many times to do you eat out per week?*

How many times do you eat raw nuts or seeds per week?*

Rate you stress level on a scale of 1-10 during the average week:*

How many times do you eat fish per week?*

How many times do you work out per week?*

List the three worst foods you eat during the average week:*

List the three healthiest foods you eat during the average week:*

Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed form attached. I must use the password Applicant#1 to open and save this attachment.

I understand that this is the third of four required forms.*

I will complete the FM Questionnaires/Evaluations after submitting this form.