Nutrition History

Your Name

Your Email

What are your favorite foods?

What are your least favorite foods?

If you drink milk what type do you drink?

How many cups a day do you drink or use?

Do you eat cheese, if yes what type and how many ounces a day?

Do you eat yogurt, if yes what type and how many cups per day?

How many servings per day of vegetables do you eat?:

If you eat vegetables, what type do you consume--fresh, frozen or canned?

How many servings of fruit do you consume per day?:

If you eat fruit, what type do you usually consume--fresh, frozen, or canned?:

Do you drink fruit juice, if yes what type and how many cups per day?

What type of bread do you buy?:

If you selected other, what type?

If you eat bread, how many slices per day?

What high fiber foods do you consume and how often?:

How many ounces of beef, lamb, and or pork do you eat per week?

How many ounces of poultry do you eat a week?

How many ounces of fish and/or shellfish do you eat a week?

How many whole eggs do you use a week?

What is your preferred method of preparation?:

What types of spreadable fats do you use?

What type of cooking oil do you use?

Do you use salt?

Do you use?

How many cups of legumes (dried peas and beans) do you use a week?

If you drink soft drinks, what type do you drink?:

Do you drink alcohol?

If yes, what is your beverage of choice?

How many glasses per week?

How many cups of water do you drink per day?

Who prepares your meals?

How many meals do you eat at home?

How many times per week do you eat in restaurants?

Do you eat in-between meal snacks?

If you snack, what types of foods do you choose and how many snacks per day?

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