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
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: 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)|
|____ small helping(s) of cooked cereal, rice or pasta||____ burrito(s)|
|____ small bowl(s) of cold cereal||____ slice(s) of pizza|
|____ 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.
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.