IPRS Nutrition Survey Form - EPNM-Sur
IPRS Mineral Balance Assessment Tool - MBaTtm

DAILY FOOD AND FLUID INTAKE FORM

First Name: Last Name:
Date (dd/mm/yy):
 

Morning - Time of Day:

Juice, Milk, Water*, Coffee, etc.
Item/Category Description Amount (Fluid Ounces)

Cereal, meat, eggs, breakfast pre-mixes, bread/toast, etc.
Item/Category Description Amount (serving size)

Mid-morning Intake - Time of Day:

Item/Category Description Amount (serving size)
Fluids*
Solids

Lunch Time - Time of Day:

Item/Category Description Amount (serving size)
Fluids*
Meat
Vegetables
Breads
Condiments

Mid-afternoon Snack - Time of Day:

Item/Category Description Amount (serving size)
Fluids*
Solids

Evening Meal - Time of Day:

Item/Category Description Amount (serving size)
Fluids*
Meat
Vegetables
Breads
Condiments

Bedtime Snack - Time of Day:

Item/Category Description Amount (serving size)
Fluids*
Solids

Supplements and Medications
Item/Category Description Amount (milligrams, micrograms or I.U.) N, L, M** Time(s) of Day (am, pm, etc.)
Vitamins (A, C, D, K)
Vitamins B1, B2, B6
Vitamin B12
Niacin, thiamine
Folic Acid
Minerals: Calcium, Phosphorous
Iron
Magnesium, Potassium
Zinc
Other Vitamins or Minerals
Medications for:        
   Blood pressure
   Nausea
   Vomiting
   Migraine
   Anxiety/      Depression
Other medications:
 

**N (normal amount), L (less than normal), M (more than normal)

*Identify the water sources such as bottled water, mineral water, well water, etc.  If tap water, has it been treated for disinfection (chlorination) or dental purposes (fluoridation)?  Would you describe it as soft, mild or hard (leaves a residue on dishes and plumbing fixtures)?  Check off  all that apply below.

Water Source Untreated Softened Municipal Hardness
Tap water Yes Yes Chlorination
Fluorination 		Low       
Medium
High      
Bottled water Distilled?
Spring?    		    Minerals added?
Yes

  Not currently active, please send completed form by email to myhealth@wwwIPRSinc.org

 For the most reliable nutritional balance report, complete the foregoing form for at least three separate days and send completed forms to the address below.  If you wish a full analysis, also complete the medical history form and return that as well. 

IPRS Nutrient Analysis,    1162 Falling Stream, Sanford, NC 27332
If you have any questions, contact us at info@iprsinc.org

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Version 8/15/2016, (c) IPRS

Program note:  Serving size may be a drop-down menu that depends upon the category.  For example for fluids it would present as fluid ounces.  For solids as different options for serving sizes.