3-Day Diet History Parent or Guardian's First Name*Parent or Guardian's Last Name*Phone Number*Email Address* Street Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code*Child's Name*Date of Birth* MM slash DD slash YYYY Instructions: You are being asked to record ALL foods and drinks consumed by your child for 3 days in a row. The following directions will guide you in filling out the form. You need to complete this history and send the information to EBS Children’s Therapy with the rest of your forms. Please fill out ALL the information at the top of the first page. Please record the DATE and DAY of the week for each day. Record ALL food and drinks eaten along with the TIME your child ate or drank them. It is best to carry a log with you and to record items immediately so that nothing is missed. Include an EXACT description of the item and your best guess of the portion size of the amount eaten. Write the brand name of formula your child is on (i.e. Enfamil, Prosobee, etc.), what type of juice he/she drank (i.e. apple, grape, etc.), any special recipes for drink mixtures your child uses (i.e. 24 calorie Isomil + 1 tsp Polycose), and any additions to foods (i.e. ¼ cup mashed potatoes + 1 Tbsp margarine). Be sure to include dressings, sauces, gravies, or anything extra. It is suggested that you may wish to use measuring spoons and cups when serving your child for these 3 days to report the amounts eaten/ drank better. Does your child take a vitamin or mineral supplement?* Yes No Name and amount: Formula MixingNumber of scoops:Amount of water:Select which statement applies. I put water in the bottle first then the formula powder. I put the formula powder in the bottle first then the water. The formula is liquid in a can and I do not add anything. Day 1Click the plus sign (+) on the right to add rows.DateTimeFood/Drink ItemAmountBottle?Cup?Mouth?G-Tube? Day 2DateTimeFood/Drink ItemAmountBottle?Cup?Mouth?G-Tube? Day 3DateTimeFood/Drink ItemAmountBottle?Cup?Mouth?G-Tube?