Author: Andrea

Patient ID ______________________

Nutrition Diary

Nutrition Diary
When your family member (the patient) is able to eat by mouth, please record what they eat and drink each day . This is an estimate for you to see how well your family member is eating.
The patient, if they are able to, and all family and friends are welcome to make entries into the diary.
It is valuable to share a meal with the your family member in hospital since meals are social times and it can be motivating to the family member to eat and get better.
The following pages of this diary are to be used to record how much your family member is eating. Here are some instructions:
Each page corresponds to 1 calendar day.
Try to visit your family member for some meal times so that you may directly observe how much food your family member is actually eating.
Record the amount of food and oral nutrition supplements you observe your family member consume at a meal.
If you are not present for a meal, you may ask a nurse, another member of the health care team or your family member to complete the diary.
Please record your family member’s intake as often as possible while they are in hospital, for up to 2 weeks after their breathing tube has been removed (extubation).
Please leave the nutrition diary at your family member’s bedside so that it can be used by other family members when they visit.

If your family member continues to receive tube feeding (enteral) or IV (parenteral) nutrition and is not receiving food by mouth, you do not need to complete the diary. We encourage you to continue to monitor the amount of nutrition your family member is receiving. Any questions or concerns you have can be discussed with the nurses, doctors or Dietitians on the hospital ward.
If you have any questions, please feel free to contact:
______________________________________________
______________________________________________
______________________________________________
If at any time you are concerned about your family member’s nutrition, please speak with the nurse or dietitian.

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Date (DD/MM/YYYY): _________________________________

Did your family member take any nutritional supplements today (i.e. Boost, Ensure)?
Yes —> How many (to the nearest 1/4 bottle)?
No

Meal: Breakfast
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

I am a family member and (choose one): Directly observed this meal / I recorded the intake that was reported to me by: / Nursing Staff Dietary Staff Physician / The patient Other (specify):________________

x

Nothing

1/4

1/2

3/4

All

Meal: Lunch
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

Meal: Dinner
I am a family member and (choose one): Directly observed this meal
I recorded the intake that was reported to me by:
Nursing Staff Dietary Staff Physician
The patient Other (specify):________________
Place an ‘X’ in the correct plate to show how much your family member ate, i.e.

x

Nothing

1/4

1/2

3/4

All

18-July-2016 # #

Date (DD/MM/YYYY): _________________________________

18-July-2016 #