Patient Education:
Food Habits Survey
Copyright © 2017 by the American Academy of Family Physicians
1
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Food Habits Survey
Copyright © 2017 by the American Academy of Family Physicians
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.
Keyword(s): daily intake;diet;food;food groups;food pyramid;habits;intake;nutrition;patient
education;patient informationandrecommended foods
A survey to help you and your doctor identify
description
your food habits.
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
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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: Your Daily Diet
Grains Mixed Foods
____ small square(s) of
____ slice(s) of bread
lasagna
____ small serving(s) of
____ tortilla(s)
spaghetti with meat sauce
____ small serving(s) of
____ small roll(s), biscuit(s) or muffin(s)
macaroni and cheese
____ 1/2 bun(s), English muffin(s) or
____ taco(s)
bagel(s)
____ small helping(s) of cooked cereal,
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rice or pasta ____ burrito(s)
____ small bowl(s) of cold cereal ____ slice(s) of pizza
Vegetables Beverages
____ scoop-sized helping(s) of ____ cup(s) of regular
vegetables 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,
____ 12-ounce diet drinks
banana, slice of melon, etc.)
____ glass(es) of Kool-Aid
____ 1/2 cup(s) cooked or canned fruit
or fruit punch
____ small glass(es) of fruit juice ____ glass(es) of water
Dairy Sweets and Fats
____ sweet roll(s) or
____ glass(es) (8 ounces) of whole milk
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 ____ 10 chips or french
cheese fries
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____ rounded teaspoon(s)
____ 1/2 cup(s) of ice cream
of margarine or butter
____ tablespoon(s) of
salad dressing
Meat or Meat Alternatives
____ small piece(s) of meat, fish or
Alcohol
poultry (about the size of a deck of cards)
____ 2 eggs ____ 12-ounce beer(s)
____ 4 ounces of wine
____ 1 cup(s) cooked dried beans or peas
(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. American Academy of Family
Physicians, Leawood, KS. 2001.
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