Patient name: ………………………
1: Food group
Recommended daily intake Daily intake Amount to supplement
Grains (bread, rice and noodles) 80 -170 grams of whole grains
Vegetables 2.5 cups
Fruit 2 cups
Milk 3 glasses of milk
Meat or meat substitutes 140 - 180 grams
2: Fat, oils and sweets
Recommend: limited use
The amount you eat: ………………………
Recommendation: Drinks should provide water and nutrients without too many calories.
Problems in current drink selection: ………………………
Take note of the suggestions for your new diet:
____ Eat plenty of whole grain breads, cereals, rice and pasta.
____ Eat more vegetables.
____ Eat much fruit.
____ Drink more milk, and eat more yogurt and cheese.
____ Eat plenty of meat, poultry, fish, dried beans, eggs and nuts.
____ Eat more low-fat meat, milk, yogurt and cheese
____ Eat less meat, eggs, nuts and dried beans and less poultry and fish.
____ Eat fewer eggs (no more than 4 eggs or yolks per week).
____ Eat less fat, oils and sweets.
____ Drink less sweet drinks.
____ Drink less alcohol.
____ Eat less salt and less foods high in sodium.
____ Low or no energy drinks, such as water, unsweetened tea, or unsweetened carbonated drinks.
Signature of doctor: ………………………
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