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.
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? ____________________________
If you take any vitamins or other dietary supplements list them here. How many of each do you take?
__________________________________________________________
__________________________________________________________
__________________________________________________________
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
Food Habits Survey
Food Habits Survey
Survey: General Information
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 and toast a day, so he wrote "2-3" in the blank beside "slice 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 of vegetables." He also has a small salad nearly every day.
Grain Products
2-3 slice of bread
___ tortilla
1 small roll, biscuit or muffin
___ 1/2 bun, English muffin or bagel
___ small helping of cooked cereal, rice or pasta
2 small bowl of cold cereal
Vegetables
2 scoop-sized helping of vegetables
1 small vegetable salad
___ medium-sized potato
Now fill out the form below to show what you eat on a typical day.
Fred usually eats 2 or 3 slices of bread and toast a day, so he wrote "2-3" in the blank beside "slice 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 of vegetables." He also has a small salad nearly every day.
Grain Products
2-3 slice of bread
___ tortilla
1 small roll, biscuit or muffin
___ 1/2 bun, English muffin or bagel
___ small helping of cooked cereal, rice or pasta
2 small bowl of cold cereal
Vegetables
2 scoop-sized helping of vegetables
1 small vegetable salad
___ medium-sized potato
Now fill out the form below to show what you eat on a typical day.
Survey: Your Daily Diet
| Grains | Mixed Foods |
| ____ slice of bread | ____ small square of lasagna |
| ____ tortilla | ____ small serving of spaghetti with meat sauce |
| ____ small roll, biscuit or muffin | ____ small serving of macaroni and cheese |
| ____ 1/2 bun, English muffin or bagel | ____ taco |
| ____ small helping of cooked cereal, rice or pasta | ____ burrito |
| ____ small bowl of cold cereal | ____ slice of pizza |
| Vegetables | Beverages |
| ____ scoop-sized helping of vegetables | ____ cup of regular coffee |
| ____ small vegetable salad | ____ cup of decaf coffee |
| ____ medium-sized potato | ____ cup of regular tea |
| ____ cup of decaf tea | |
| Fruits | ____ 12-ounce soft drinks |
| ____ piece of fruit (an apple, orange, banana, slice of melon, etc.) | ____ 12-ounce diet drinks |
| ____ 1/2 cup cooked or canned fruit | ____ glass of Kool-Aid or fruit punch |
| ____ small glass of fruit juice | ____ glass of water |
| Dairy | Sweets and Fats |
| ____ glass (8 ounces) of whole milk | ____ sweet roll or donut |
| ____ glass of 2% milk | ____ slice of pie or cake |
| ____ glass of 1% or skim milk | ____ 3 small cookies |
| ____ 1 ounce slice of cheese | ____ candy bar |
| ____ serving of yogurt or cottage cheese | ____ 10 chips or french fries |
| ____ 1/2 cup of ice cream | ____ rounded teaspoon of margarine or butter |
| ____ tablespoon of salad dressing | |
| Meat or Meat Alternatives | |
| ____ small piece of meat, fish or poultry (about the size of a deck of cards) | Alcohol |
| ____ 2 eggs | ____ 12-ounce beer |
| ____ 1 cup cooked dried beans or peas | ____ 4 ounces of wine (small glass) |
| ____ 4 tablespoons peanut butter | ____ shot of liquor |
More Information
Source
Written by familydoctor.org editorial staff.
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.
Reviewed/Updated: 05/06
Created: 09/00
Copyright © 2000-2008 American Academy of Family Physicians
|This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.
For private, noncommercial use only.
Home | Privacy Policy | Contact Us | About This Site | What's New |
|This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.
For private, noncommercial use only.
Home | Privacy Policy | Contact Us | About This Site | What's New |