FOOD DIARY - Stanford Hospital & Clinics

STANFORD CENTER FOR BARIATRIC SURGERY
Stanford University Medical Center
Department of Surgery, Boswell A-160
300 Pasteur Drive, Stanford CA 94305-5655
FOOD DIARY
This diary is intended to record your food habits, including not only eating, but also shopping and
preparing food for a minimum of one week.
Please record this during a typical week. Preferably when your activity and eating habits are as
close to normal for you as possible. Please also be as honest as you can possibly be. Our goal is to
understand where you get your calories and what eating behaviors are important to you. In this
way, we hope to know which operation is likely to work best for you. We also hope to be able to
recommend changes in your behavior, or education about your diet, that will make the operation
more successful.
You will not be denied an operation based on poor eating habits, so there is no benefit to you
to be anything less than completely honest as you fill out your food diary. Please be as complete
as possible.
INSTRUCTIONS:
Begin diary on a Monday and complete it for at least one week. Date each day.
Record the time, type of food and approximate quantity of each food, snack, or drink that you
consume throughout the day. Be sure to include soft drinks, coffee, tea, and water.
Record also where you got the meal: for example, “home,” “vending machine,” “McDonalds,”
“restaurant,” etc.

Monday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Tuesday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Wednesday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Thursday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Friday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Saturday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED

Sunday, _______________________ (date)
TIME
Did you shop at a grocery store today?
FOOD- TYPE AND QUANTITY
Did you eat at a fast food restaurant today? (List them)
Did you cook a meal today? (List them)
How many calories do you think you consumed today?
LOCATION
PURCHASED/
CONSUMED