Instructions for Your Daily Food Record
Make sure to print legibly and clearly. If you are faxing your record back, please write in a dark pen…pencil is very hard to
read from a fax machine. If you have an upcoming appointment please make sure you return the forms at least 5 days before
your appointment.
The forms can be mailed to: The forms can be faxed to:
O.H.S.U. Human Performance Lab CR110 (503) 494-1310
3181 S.W. Sam Jackson Park Road
Portland, OR 97201
Your Personal Profile: Fill in all the information at the top of the form. The computer will use this information to calculate
your Ideal Caloric Level and then compare it to your food record to identify diet deficiencies or excesses. Enter your current
weight and your desired weight. If you are currently at your desired weight, write your weight twice.
Daily Activity Level:
1-Sedentary – Limited activity, confined to a few rooms or a house. Most activities involve sitting.
2-Lightly Active – Daily activities involve mostly walking or sporadic slow running. Less than 20 minutes of brisk walking
per week. Most office workers (desk jobs).
3-Average – Activities include golf, recreational tennis, pleasure swimming, or other similar activities. Between 15 and 20
minutes of continuous running or between 30 and 45 minutes of brisk walking at least 3 times per week. Active students, child
care providers, waiters/waitresses, professional house cleaners.
4-Above Average – More than 20 minutes of sustained activity such as jogging, swimming, competitive tennis, or cross-
country skiing more than 3 times per week, OR more than 45 minutes of brisk walking at least 3 times per week. Construction
and agricultural workers, garbage collectors, mail carriers (walking).
5-Super Active – At least 1.5 hours of vigorous activity (training for competitive athletics, full court basketball, mountain
climbing, weight training, football, wrestling, or other similar activities) 4 times per week, OR more than 2.5 hours of
recreational activity 4 or more times per week. Lumberjacks, heavy manual digging.
Record your diet for 3 days (2-weekdays and 1-weekend day). BE SPECIFIC. BE HONEST.
The forms have spaces for you to enter the food description, the amount or portion size and method of preparation. (Ignore the
column for computer code.)
The Amount or Portion Size.
Enter the amount of the food in cups, teaspoons, tablespoons, slices/pieces, ounces-weight, fluid ounces and other standard
measures. Specify a piece of pie as 1/8, 1/6 or other portion. A bowl of soup or a plate of spaghetti should be entered in cups.
If you are entering foods by their weight (the most accurate) enter the weight for the edible portion – do not include the bone or
other refuse. Fluid ounces are not the same as weight ounces. For example, one cup of water is 8 fluid ounces, but weighs 8.5
ounces.
How is the food cooked?
Specify if the food is fresh (raw), frozen, prepared from canned or cooked. Was it boiled, baked, fried, steamed, broiled or
roasted? If canned, specify if it was canned in juice, water, light or heavy syrup, or drained. If it was prepared from a mix, did
you add water or milk? If you added milk, was it 1%, 2% or whole milk?
Recipes and Condiments.
For combination foods and recipes, break down the item into its ingredients or components. For example, for a pasta salad – 1
cup cooked noodles, 2 TBS celery, 1 TBS onions, etc. For a sandwich, enter the components – 2 slices of turkey, 2 slices of
tomato, and any spices or condiments – 1 TBS light mayo, mustard, etc.
Breads and Milks.
Be sure to specify the type of bread – white, whole wheat, 9-grain, sourdough, etc. Also specify whether the milk is nonfat, 1%,
2%, or whole milk.
Specialty Items and Supplements.
If you consume unique food items or supplements please include either a copy of the nutrition label or a handwritten list of the
basic nutrition facts from the package.