Food Habits Survey

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

Survey: Your Daily Diet

GrainsMixed 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
VegetablesBeverages
____ 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
DairySweets 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.