Food Habits Survey

It is common for your doctor to want to know about your food habits. They may want to collect data to help create a health care plan. Below is a complete food habits survey. Please respond to all sections as best as possible. Then, review the results with your doctor.

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?

___ beef, steak, pork chops       ___ chicken, turkey, fish

If you don’t eat meat, what types of protein do you buy? ___________

___________________________________________________________________________

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 foods when you cook?

___ Yes ___ No

Do you add salt to your food at the table?

___ Yes ___ No

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) or burrito(s)
____ small helping(s) of cooked cereal, rice, or pasta____ hamburger(s)
____ small bowl(s) of cold cereal____ slice(s) of pizza
VegetablesBeverages
____ scoop-sized helping(s) of vegetables____ glass(es) of water
____ small vegetable salad(s)____ cup(s) of regular coffee
____ medium-sized potato(es)____ cup(s) of decaf coffee
____ cup(s) of regular tea
Fruits____ cup(s) of decaf tea
____ piece(s) of fruit (an apple, orange, banana, slice of melon, etc.)____ 12-ounce soft drinks
____ 1/2 cup(s) cooked or canned fruit____ 12-ounce diet drinks
____ small glass(es) of fruit juice____ glass(es) of Kool-Aid or fruit punch

____ energy drinks

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
Other

 

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.

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