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
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|
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. Orenschools, Leawood, KS. 2001.
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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.