It is common for your doctor to want to know about your food habits. He or she 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
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
|____ 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|
|____ 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
|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|
Things to consider
If you have certain health conditions, such as diabetes or heart disease, talk to your family doctor about nutrition. You may need to adjust your healthy eating to address your health conditions.
Questions to ask your doctor
- Are most commercial diet programs and fad diets healthy?
- What should I do if I am trying to lose weight?
- Are these guidelines the same for adults and children?
Copyright © American Academy of Family Physicians
This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.