Food Intake Assessment

If you follow a special diet/nutritional program, check the following that apply:
Low Fat Low Carb High Protein Low Sodium No Gluten Vegetarian Vegan Diabetic No Dairy No Wheat Weight Loss Other
Which meals do you eat regularly?
Breakfast Snacks (Mid Morning) Lunch Snacks (Afternoon) Dinner Snacks (Late night) Other
The nutrition/eating habits that are most challenging for me are:

The nutrition/eating habits

The nutrition/eating habits that I am most proud of are:

I am proud of my nutrition/eating habits

How much water, in ounces, do you drink a day?

5

How many times a week do you drink the following?
More than 2 servings a day One serving a day Once a week Once a month Rarely Never In the Past
Coffee Regular (8 oz cup)
Coffee Decaf (8oz cup)
Tea
Juice (8 oz serving)
Soda (12 oz can)
Diet Soda (12 oz can)
Energy Drinks
Milk (8 oz)
Milk Alternatives
How do you take your coffee?
Decaf Regular Milk Sugar Iced Cold Brew Other
What type of milk do you drink?
Please indicate the frequency that you eat the following:
Never 2-3 times per month 1 time per week 2-3 times per week 1 time per day 2-3 times per day
Fast food
Reastaurant food
Vending machine food
Cafeteria or buffet food
Forzen meals
Home-cooked meals
Leftovers
Beef (hamburger, steak, etc.)
Pork (chop, loin, ham, bacon, etc.)
Liver
Lamb
Poultry (chicken, turkey, etc.)
Deli meat
Fish
Soyfoods
Beans
Crackers
Cookies, cakes, muffins
Whole grains
Fresh/Raw vegetables
Cooked vegetables
Fruit, fresh or frozen
Canned Vegetables or Fruit
Margarine
Dairy (Milk, yogurt, cheese, butter)
French fries
Fired meat (chicken, fish)
Foods with added sweeteners/sugar
Artificial Sweeteners
Meal replacements (ex. slim fast)
What types of food cravings do you have? Please describe:

Food cravings

What types of foods do you dislike? Please describe:

Foods dislike

Eating Style: Based on how you eat on a regular basis, please check all that apply:
Fast eater Erratic eater Emotional eater (stressed, bored, sad, etc.) Late night-eater Time constraints Dislike "healthy" food Travel frequently Do not plan meals/menus Rely on convenience items Family member(s) have different tastes Love to eat Eat too much Eat because I have to Negative relationship with food Struggle with eating issues Confused about food/nutrition Frequently eat fast food Poor snack choices Other
The food/nutrition questions that I would like to ask are:

Food/nutrition related questions.

Edit
If you follow a special diet/nutritional program, check the following that apply:
Low Fat Low Carb High Protein Low Sodium No Gluten Vegetarian Vegan Diabetic No Dairy No Wheat Weight Loss Other
Which meals do you eat regularly?
Breakfast Snacks (Mid Morning) Lunch Snacks (Afternoon) Dinner Snacks (Late night) Other
How many times a week do you drink the following?
More than 2 servings a day One serving a day Once a week Once a month Rarely Never In the Past
Coffee Regular (8 oz cup)
Coffee Decaf (8oz cup)
Tea
Juice (8 oz serving)
Soda (12 oz can)
Diet Soda (12 oz can)
Energy Drinks
Milk (8 oz)
Milk Alternatives
How do you take your coffee?
Decaf Regular Milk Sugar Iced Cold Brew Other
What type of milk do you drink?
Please indicate the frequency that you eat the following:
Never 2-3 times per month 1 time per week 2-3 times per week 1 time per day 2-3 times per day
Fast food
Reastaurant food
Vending machine food
Cafeteria or buffet food
Forzen meals
Home-cooked meals
Leftovers
Beef (hamburger, steak, etc.)
Pork (chop, loin, ham, bacon, etc.)
Liver
Lamb
Poultry (chicken, turkey, etc.)
Deli meat
Fish
Soyfoods
Beans
Crackers
Cookies, cakes, muffins
Whole grains
Fresh/Raw vegetables
Cooked vegetables
Fruit, fresh or frozen
Canned Vegetables or Fruit
Margarine
Dairy (Milk, yogurt, cheese, butter)
French fries
Fired meat (chicken, fish)
Foods with added sweeteners/sugar
Artificial Sweeteners
Meal replacements (ex. slim fast)
Eating Style: Based on how you eat on a regular basis, please check all that apply:
Fast eater Erratic eater Emotional eater (stressed, bored, sad, etc.) Late night-eater Time constraints Dislike "healthy" food Travel frequently Do not plan meals/menus Rely on convenience items Family member(s) have different tastes Love to eat Eat too much Eat because I have to Negative relationship with food Struggle with eating issues Confused about food/nutrition Frequently eat fast food Poor snack choices Other
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