Diet and Lifestyle Record

The purpose of the diet and lifestyle record is to help us understand the intake of sugar, carbohydrates and acidic foods and beverages in relationship to your lifestyle and activity.   It is important to note when, where and how much is ingested.  Anything that goes into the mouth should be recorded.

Please choose a typical schedule, do not wait for a quiet time in your life as this will not show how in a busy schedule you or your child eats, drinks or sleeps. This will help us to work together to create a plan to reduce the risk of decay in an infectious environment.

Please Include:


Whether it is over the counter or prescription medication the type of medication (ex allergy medication), the form (whether tablet or liquid), the frequency ( ex. morning and night) and whether taken in food or with a


Including water, juice, pop, coffee, tea, alcohol and any extras added to the drinks such as cream and sugar. Include amount and how long it took to finish the drink.


Please include all meals, any condiments (ex. ketchup, syrup, jam, mustard, hot sauce, plum sauce,  mayonnaise etc, seasonings (salt and pepper), cheese or cheese sauce, sprinkles of sugar etc) used what time and how much.


Include anything that is eaten between main meals – even a bite – how long it takes to eat the snack and the time it is eaten.


Record the activities during the time that diet is recorded.  Such as dance, gymnastics, hockey or soccer. The length of the activity and the time. Wake up time and bedtime should also be recorded.

Oral Care

Include the brushing routine, the time the teeth are brushed, what products are used (ex mouth wash)

Name: ______________________________________   Date Started: ____________

D.O.B.: ________________________   Completed by:   _____________________________

Day:  ______

Wake up time:
What: When: How long:
What: When: How long:
What: When: How long:
Snacks and drinks
What: When: How long:
What was the activity: When was the activity: How long was the activity:
Oral Care:
What was used: When was this done: How long did it take:
What was taken: What time was medication taken: How was it taken:
Bedtime and night habits: