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Eating Pattern Questionnaire

Questionnaire

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ijalanatomi2610
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35 views1 page

Eating Pattern Questionnaire

Questionnaire

Uploaded by

ijalanatomi2610
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Eating Pattern Questionnaire

Name: _______________________________________ Date: __________________________

Please answer the following questions and check the appropriate boxes that most closely describe your eating patterns.

1. Do you follow a special diet? 6. How many times each day do you have
No Diabetic Low sodium the following food items?
Low fat Kosher Vegetarian Other a. Starch (bread, bagel, roll, cereal, pasta, noodles,
Give examples of what guidelines or diets, if any, you follow rice, potato)
________________________________________________ Never Less than 1 1-2 3-5 6-8 9-11
________________________________________________
b. Fruit
2. Which do you regularly eat? Never Less than 1 1-2 3-5 6-8 9-11
Breakfast Lunch Brunch Dinner
c. Vegetables
3. When do you snack? Never Less than 1 1-2 3-5 6-8 9-11
Morning Afternoon Evening Late night
Throughout the day d. Dairy (milk, yogurt)
Never Less than 1 1-2 3-5 6-8 9-11
What are you favorite snack foods?
_________________________________________________ e. Meat, fish, poultry, eggs, cheese
_________________________________________________ Never Less than 1 1-2 3-5 6-8 9-11

4. Do you eat out or order food in? f. Fat (butter, margarine, mayonnaise, oil, salad
Yes No dressing, sour cream, cream cheese)
Never Less than 1 1-2 3-5 6-8 9-11
How often?
Daily Weekly Monthly Other g.. Sweets (candy, cake, regular soda, juice)
Never Less than 1 1-2 3-5 6-8 9-11
What kind of restaurant(s)/eating facilities?
___________________________________________________ 7. What beverages do you drink daily and how much?
___________________________________________________ Water ______ times or glasses per day (8 oz)
Coffee ______ times or cups per day
What kinds of cuisine? Tea ______ times or cups per day
___________________________________________________ Soda ______ times or glasses per day (12 oz)
___________________________________________________ Alcohol ______ times or glasses per day (12 oz)
Other ______ times or glasses per day
5. How is your food usually prepared? (check all that apply) Specify ___________________________________
Baked Broiled Boiled
Fried Steamed Poached Other 8. Would you like to change your eating habits?
Yes No

Which habits would you like to change?


__________________________________________
__________________________________________
__________________________________________

Adapted with permission from the Wellness Institute, Northwestern Memorial Hospital.

2820 Ohio Street / Augusta, KS 67010 phone: (316) 775-7500 fax (316) 775-3685

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