Food Habits Survey

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


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


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





____ 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


____ 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




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)


____ 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