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 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

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