NUTRITION ASSESSMENT

NUTRITION ASSESSMENT

24-Hour Dietary Recall Template

Person’s first and last initials: Age:

Date assessment was done: Date of dietary recall:

TimeFood eatenAmount eatenTotalcaloriesCalories from proteinCalories from fat
NutrientCurrent national dietary recommendationsAmount consumed in 24 hour period
Calories
Protein (grams per day)
Protein (percentage of total calories)
Fat (grams per day)
Fat (percentage of total calories
Vegetables (# of servings/day)
Fruits (# of servings/day
Grains (# of servings/day
Dairy (# of servings/day)
Water (mL/day)
Fiber (grams per day)