Food Nutrition Chart
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Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements DATE: BREAKFAST Cereal Toast / bread (no of slices) Marg ( ) Preserves ( ) tick if yes Other Drink SNACK Drink LUNCH Main course Potato / rice Vegetable Dessert / fruit Other Drink SNACK Drink EVENING MEAL Sandwich Main course Vegetable Potato / rice Dessert / fruit Other Drink SNACK 0 0 1/4 1/4 1/2 1/2 3/4 3/4 All All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All teaplate size portion YES / NO 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All teaplate size portion YES / NO 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All 0 1/4 1/2 3/4 All DATE: BREAKFAST Cereal Toast / bread (no of slices) Marg ( ) Preserves ( ) tick if yes Other Drink SNACK Drink LUNCH Main course Potato / rice Vegetable Dessert / fruit Other Drink SNACK Drink EVENING MEAL Sandwich Main course Vegetable Potato / rice Dessert / fruit Other Drink SNACK 0 0 1/4 1/4 1/2 1/2 3/4 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 teaplate size portion YES / NO 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 teaplate size portion YES / NO 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 0 1/4 1/2 3/4 All All All All All All All All All All All All All All All All All All All All All All EVALUATION Action taken following evaluation of 4 days intake : Qualified nurse signature..................
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