Diet History Information

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Food Frequency Questionnaire

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This questionnaire is designed to help me learn more about your eating habits, so that we can identify key areas to support your reaching your nutrition goals.

  1. Please provide the following information:

    First Name
    Last Name
    Middle Initial
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Work Phone
    Home Phone
    FAX
    E-mail
  2. Do you have any particular concerns/questions regarding your food choices, eating habits and/or overall nutritional status.

    The next section asks about your usual eating habits. For each question, select the response which best describes your usual behavior over the past year.

  3. How many days each week do you eat breakfast?

    None
    1-2 days
    3-5 days
    6-7 days

  4. What is your usual pattern for the evening meal?

    This is my biggest meal
    Medium size meal
    Light meal
    Seldom eat in the evening

  5. Do the type of meals you usually eat include the following?

    Red meats
    Fish or chicken, but no red meats
    Vegetarian meals with dairy or eggs
    Vegan - no animal foods

  6. How much water do you drink each day?

    rarely
    1-2 cups
    3-5 cups
    >5 cups

  7. When salting your food, do you usually salt it?

    Freely
    Moderately
    Sparingly
    Never

  8. Do you use non fat or low fat products?

    Never
    Rarely
    Sometimes
    Regularly

  9. What kind of spread do you use most often?

    Butter
    Stick margarine
    Soft tub margarine
    none of these

  10. What other kinds of fat do you use most often?

    Shortenings, lard and/or animal fat
    Vegetable oils
    Use all of the above about the same
    None of these

  11. Does your work or daily activity primarily involve the following?

    Sitting/driving
    Standing
    Walking or other active exercise
    Heavy labor (eg. heavy lifting, etc)

  12. Outside of your normal work or daily responsibilities, how often do you engage in exercise of 20 minutes or more which markedly increase your breathing (such as vigorous walking, cycling, running, swimming)?

    Seldom or never
    Less than once a week
    1-2 times per week
    3-5 times per week
    6 or more times per week

  13. Do you currently take a multi-vitamin?

    Never
    Rarely
    Sometimes
    Regularly

  14. Do you take any other vitamin or mineral supplement?

    Antioxidants
    Calcium
    Iron
    Other


  15. Do you take any nutritional supplements?

    Never
    Rarely
    Sometimes
    Regularly

    The next section asks about your eating patterns during the past year. For each food, indicate your usual intake of that food per day, week, or month. For example: Eggs. If you eat 2 eggs every day, enter 2 under daily. If you average 2 eggs a week over the year, enter 2 under weekly. If you do not eat the food or if you have it rarely, then do not mark a frequency or interval. This questionnaire will take about 20 minutes to complete. The accuracy of your nutrition report depends on the accuracy of your answers.

    reference quantity Daily Weekly Monthly

    Breads, cereals and grain products

    Whole grain breads (whole wheat, rye, pumpernickel) 1 slice
    White breads (French-1 slice, hamburger/hot dog bun 1/2) 1 item
    English muffin, bagel, pita bread 1/2 item
    Whole grain crackers: Triscuits, Wheat Thins, etc.                        5 items
    Other crackers: Saltines, Ritz, etc                                        5 items
    Tortilla, corn 6" diameter 1 item
    Muffins 1 item
    Pancakes (2), waffles (7" diameter, 1) 1 svg
    Whole grain hot cereal: oatmeal, wheat    1/2 cup
    Instant or quick hot cereal: cream of wheat, cream of rice 1/2 cup
    Cold cereals shredded wheat, raisin bran or bran flakes 3/4 cup
    Cold cereals, with added sugar 3/4 cup
    Rice, cooked 1/2 cup
    Pasta, cooked 1/2 cup

    Fruits and Juices

    Apple or pear, fresh, medium 1 item
    Banana, medium 1 item
    Orange (1 item) or grapefruit (1/2 item) 1 svg
    Peach (1), nectarine (1/2) or apricots (2) 1 svg
    Peach (1), nectarine (1/2) or apricots (2) 1 svg
    Berries (in season) 3/4 cup
    Cantaloupe, medium (in season) 1/4 item
    Other melon (watermelon, honeydew, casaba) 1 c  
    Pineapple, fresh (1/2 c)  
    Dried fruits: raisins (2 T), dates (2), prunes (2), dried apricots (4)  1/4 c  
    Canned fruit or frozen fruit 1/2 c  
    Orange or grapefruit juice 1/2 c  
    Tomato juice or vegetable juice 1/2 c  
    Other juices: apple, grape, pineapple, or cranberry 1/2 c  
    Fruit drinks: lemonade, punch, Koolaid 1/2 c  

    Fats and Oils

     
    Vegetable oils: corn, safflower, soy, etc. 1 T
    Olive oil 1 T
    Shortening 1 T
    Lard 1 T
    Margarine 1 T
    Butter 1 T
    Mayonnaise 1 T
    Regular salad dressings 1 T
    Low-calorie dressings 1 T
    Sour cream 1 T
    Cream cheese 1 T
    Half & Half, table cream 1 T

    Milk, Yogurt and Cheeses

     
    Skim milk or low fat milk 1 cup
    Whole milk 1 cup
    Chocolate milk 1 cup
    Yogurt 1 cup
    Cheese: cheddar, Colby, American, Monterey Jack, etc. 1 oz
    Other cheeses: Swiss, mozzarella, ricotta, string, etc. 1 oz
    Cottage cheese 1/2 c

    Vegetables

     
    Salads: lettuce, celery, green peppers, onions 1 c
    Dark green leafy vegetables, raw or cooked 1/2 c
    Carrots, raw or cooked 1/2 c
    Tomatoes, fresh, medium 1 item
    Starchy vegetables, cooked: corn, peas, mixed vegetables 1/2 c
    Other vegetables, cooked: green beans, beets, zucchini 1/2 c
    Cauliflower, broccoli, Brussels sprouts, cabbage 1/2 c
    Winter squash, cooked: acorn, butternut, hubbard 1/2 c
    White potato, baked, boiled, or mashed (medium) 1 item
    Sweet potatoes or yams, cooked    1/2 c

    Beverages

     
    Cola drinks (1 can = 12 fl oz) 12 fl oz
    Diet cola drinks (1 can = 12 fl oz)    12 fl oz
    Non-cola drinks: 7-Up, Sprite, Slice, etc (1 can = 12 fl oz) 12 fl oz
    Diet non-cola drinks (1 can = 12 fl oz) 12 fl oz
    Coffee or tea (1 cup = 8 fl oz) 8 fl oz
    Decaffeinated coffee or teas: Sank, herbal tea, etc. 8 fl oz
    Hot chocolate or cocoa 8 fl oz
    Beer (1 can = 12 fl oz) 12 fl oz
    Wine, dry or table (red, white or blush) 4 fl oz
    Liquor: vodka, whiskey, gin, rum, etc. 1.5 fl oz

    Protein foods

     
    Legumes: lentils, pinto beans, navy beans, cooked 1 c
    Nuts and seeds: peanuts, almonds, sunflower seeds, etc 1/4 c
    Peanut butter, nut butters 1 T
    Tofu or other meat substitutes 3 oz
    Beef rib roast, steak, pot roast, veal, etc. 3 oz
    Beef, ground, cooked 3 oz
    Pork chops, roast ham 3 oz
    Lamb: chops roast 3 oz
    Poultry: chicken, turkey, duck 3 oz
    Fish, canned with oil: tuna, sardines 3 oz
    Tuna, water pack 3 oz
    Fish: fresh or frozen, no breading: trout, halibut, sole, etc. 3 oz
    Shellfish, shrimp, scallops, lobster, clams 3 oz
    Eggs, whole large 1 item
    Egg substitutes or egg whites 1/4 c
    Lunch meats: bologna, salami, etc. 1 oz
    Frankfurters or sausage: link 4 in x 1 1/8 in 1 item

    Desserts and Sweets

     
    Cookies: chocolate chip, oatmeal, peanut butter, etc. 2 item  
    Brownies, 2 in 1 item  
    Doughnut or sweet roll 1 item  
    Cake, 1/12 of 9 in.  
    Granola bars (1 item) or granola (1/2 cup)  
    Pie, 1/8 of whole pie 1 sl  
    Gelatin, flavored 1/2 c  
    Pudding or custard 1/2 c  
    Ice cram 1/2 c  
    Ice Milk 1/2 c  
    Sherbet 1/2 c  
    Candy bar, chocolate bar (1 bar), M&Ms (1 pkg) 1 item  
    Hard candy, gum drops, Lifesavers  

    Miscellaneous

     
    Fast food - pizza 1 sl  
    Fast food - hamburger or cheeseburger 1 item  
    Fast food - burrito or taco 1 item  
    Bacon 2 sl  
    Popcorn, popped 2 c  
    Potato chips, corn chips, tortilla chips 1 oz  
    Catsup or chilli sauce 1 T  
    Tomato based sauce (spaghetti sauce) 1/2 c  
    Pickles or pickle relish 1 T  
    Olives 5 item  
    Avocado (1/8 item)  
    Sauces: soy sauce, steak sauce, barbecue sauce 1 T  
    Brown gravy, giblet; gravy or white sauce 1/4 c  
    Soups, vegetable, or noodle type 1 c  
    Soups, cream 1 c  
    Chewing gum 1 item  
    Sugar, honey, jam, jelly, syrups 1 T  

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Copyright 1999 Marla Heller, MS, RD. All rights reserved.
Revised: 03/07/05

 

1999 - 2010 Transitions Nutrition Consulting

Northbrook IL, tel 888-794-0788.

If you have any comments or questions, email us at info@netRD.com. This page was last updated on January 09, 2010.

Original web design by Julie Wehmeyer, while she was a dietetic intern at UIC