Daily Intake Assessment Form

Daily Intake Assessment Form
Record your daily food, fluid, and supplement intake along with your well-being for the day.
Date of Intake*
MonthDayYear
Date
Full Name*
First NameLast Name
Please indicate your age group*

Please record your meals and snacks for today*

Rows	Food/Drink Item	Meal Type	Quantity/Portion Size	Estimated Calories (if known)
Item 1
Item 2
Item 3
Item 4
Item 5

How much water did you drink today?*
CoffeeTeaJuiceSodaMilkOther
YesNo
If yes, please list supplements or medications and amounts taken
On a scale of 1 to 10, how would you rate your overall well-being today? (1 = Poor, 10 = Excellent)*

1
2
3
4
5
6
7
8
9
10
1 is Poor, 10 is Excellent
FatigueHeadacheDigestive issuesMood changesNo symptomsOther
Additional comments or notes about your intake or well-being today
Should be Empty: