Food Habits Survey

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Your doctor would like some information about your usual food habits to help plan the best possible health care for you.

Please complete all sections as completely and accurately as possible.

Survey: General Information

Name ________________________

Date _________________________

Who shops for food at your home? ____________________________

Who prepares it? ____________________________

What do you drink during the day? ____________________________

What kind of meat do you usually buy?
___ hamburger, steaks, pork chops ___ chicken, fish

What type of meal or meals do you prepare most often?
___ fry ___ bake ___ broil ___ stew/slow cook ___ grill

How many times a day do you eat? ____________________________

What do you usually eat? ____________________________

How many times do you eat out during the week? ___________________

What restaurant do you go to most often? ____________________________

List any vitamins or dietary supplements you take here. How many of each do you take? How often?
__________________________________________________________
__________________________________________________________
__________________________________________________________

If you eat any special foods for health or personal reasons, list what kind and how much.
__________________________________________________________
__________________________________________________________
__________________________________________________________

Do you add salt to your food at the table?
___ Yes ___ No

Do you add salt to foods when you cook?
___ Yes ___ No

Sample Survey

The sample Food Habits Survey for Fred shows what he eats in a day from two food groups: Grain Products and Vegetables.

Fred usually eats 2 or 3 slices of bread or toast a day, so he wrote "2-3" in the blank beside "slice(s) of bread." He eats a roll most days. He has a large bowl of cold cereal for breakfast, so he wrote in "2" because it's about the size of 2 small bowls. Fred usually has 2 helpings of vegetables a day, so he wrote "2" on the line for "scoop-sized helping(s) of vegetables." He also has a small salad nearly every day.

Grain Products

2-3 slice(s) of bread

___ tortilla(s)

1 small roll(s), biscuit(s) or muffin(s)

___ 1/2 bun(s), English muffin(s) or bagel(s)

___ small helping(s) of cooked cereal, rice or pasta

2 small bowl(s) of cold cereal

Vegetables

2 scoop-sized helping(s) of vegetables

1 small vegetable salad(s)

___ medium-sized potato(es)

Now fill out the form below to show what you eat on a typical day.

Survey: Your Daily Diet

Grains Mixed Foods
____ slice(s) of bread ____ small square(s) of lasagna
____ tortilla(s) ____ small serving(s) of spaghetti with meat sauce
____ small roll(s), biscuit(s) or muffin(s) ____ small serving(s) of macaroni and cheese
____ 1/2 bun(s), English muffin(s) or bagel(s) ____ taco(s)
____ small helping(s) of cooked cereal, rice or pasta ____ burrito(s)
____ small bowl(s) of cold cereal ____ slice(s) of pizza
   
Vegetables Beverages
____ scoop-sized helping(s) of vegetables ____ cup(s) of regular coffee
____ small vegetable salad(s) ____ cup(s) of decaf coffee
____ medium-sized potato(es) ____ cup(s) of regular tea
  ____ cup(s) of decaf tea
Fruits ____ 12-ounce soft drinks
____ piece(s) of fruit (an apple, orange, banana, slice of melon, etc.) ____ 12-ounce diet drinks
____ 1/2 cup(s) cooked or canned fruit ____ glass(es) of Kool-Aid or fruit punch
____ small glass(es) of fruit juice ____ glass(es) of water
   
Dairy Sweets and Fats
____ glass(es) (8 ounces) of whole milk ____ sweet roll(s) or donut(s)
____ glass(es) of 2% milk ____ slice(s) of pie or cake
____ glass(es) of 1% or skim milk ____ 3 small cookies
____ 1 ounce slice(s) of cheese ____ candy bar(s)
____ serving(s) of yogurt or cottage cheese ____ 10 chips or french fries
____ 1/2 cup(s) of ice cream ____ rounded teaspoon(s) of margarine or butter
  ____ tablespoon(s) of salad dressing
Meat or Meat Alternatives  
____ small piece(s) of meat, fish or poultry (about the size of a deck of cards) Alcohol
____ 2 eggs ____ 12-ounce beer(s)
____ 1 cup(s) cooked dried beans or peas ____ 4 ounces of wine (small glass)
____ 4 tablespoons peanut butter ____ shot(s) of liquor

 

Some information adapted from Physicians Guide to Outpatient Nutrition, by Sylvia A. Moore, Ph.D., R.D., F.A.D.A. and John P. Nagle, M.P.A. American Academy of Family Physicians, Leawood, KS. 2001.

Written by familydoctor.org editorial staff

Reviewed/Updated: 07/10
Created: 09/00

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