Food Habits Survey 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 Name ________________________ Date _________________________ Who __________ for food at your home? ____________________________ Who prepares it? ____________________________ What do you drink during the day? ____________________________ What kind of meat do you usually __________? _______ Zabiha halal, ___ 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 __________ 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 The sample Food Habits Survey for Fred shows what he eats in a day from two food groups: Grain Products and Vegetables. Fred usually eats 2 or 3 slices of bread or toast a day, so he wrote "2-3" in the blank beside "slice(s) of bread." He eats a roll most days. He has a large bowl of cold cereal for breakfast, so he wrote in "2" because it's about the size of 2 small bowls. Fred usually has 2 helpings of vegetables a day, so he wrote "2" on the line for "scoop-sized helping(s) of vegetables." He also has a small salad nearly every day. Grain Products 2-3 slice(s) of bread ___ tortilla(s) 1 small roll(s), biscuit(s) or muffin(s) ___ 1/2 bun(s), English muffin(s) or bagel(s) ___ small helping(s) of cooked cereal, rice or pasta 2 small bowl(s) of cold cereal Vegetables 2 scoop-sized helping(s) of vegetables 1 small vegetable salad(s) ___ medium-sized potato(es) Now fill out the form below to show what you eat on a typical day. 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) ____ small helping(s) of cooked cereal, rice or pasta ____ burrito(s) ____ small bowl(s) of cold cereal ____ slice(s) of pizza Vegetables Beverages ____ 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