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

Grains Mixed 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
Vegetables Beverages
____ 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
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. Orenschools, Leawood, KS. 2001.

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