Food Frequency Survey
Fresh Perspectives Nutrition Counseling
*Required
Name
Date of Birth
*Required
*Valid Date of Birth Required (format MM/DD/YYYY)
Please indicate the number of servings you consumed from each of the following food groups in the last 24 hours or other specific 24 hour period.
Keep a food record for a typical day before completing this survey.
Write down everything you ate in one 24 hour period. Then estimate the number of servings you consumed from each of the following food groups.
Please consider the serving size. For example, if you ate one cup of steamed green beans, then count that as two servings of a non-startchy vegetable. A single serving of a non-starchy vegetable is 1/2 cup cooked or 1 cup raw. Consequently, one cup of cooked string beans will be 2 servings.
Consider the examples below of single serving sizes as you complete this survey.
Date of 24 Hour Period
*Valid Date Required (format MM/DD/YYYY)
Grains and Starches
Refined Grains, Cereals and Breads
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 slice white bread, 1/2 cup cooked white rice or regular pasta, 1/4 bagel or 1/2 English muffin, hamburger bun or pita bread, 3 cups (G and S)
Whole Grains, Cereals and Breads
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 slice whole grain bread, 1/2 cup cooked oatmeal, whole grain pasta, or cooked brown rice (G and S)
Fruits
Fruits
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 whole small or medium fresh fruit, 1/2 cup chopped, cooked, or canned fruit, 1/4 cantaloupe melon, 1/2 grapefruit, 3/4 cup (6oz) fruit juice, 2 tbsp raisins or diced dried fruit pieces (Fruit)
Vegetables
Non-Starchy Vegetables
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 cup raw, leafy salad greens such as lettuce, endice, escarole, 1/2 cup cooked vegetables, 1 cup chopped raw vegetables, 3/4 cup vegetable juice, 1/2 cup spaghetti sauce (NSV)
Starchy Vegetables
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1/2 medium or 1/4 large baked potato with skin, 10 French fried potatoes (add 1/2 fat), 1/4 cup homemade potato salad, 1 cup squash, 1/2 cup yam or sweet potato pieces, 1/2 cup green peas (G and S)
Milk
Milk, Whole
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 cup (8 oz) 4.5% fat whole milk, 3/4 cup plain or artificially sweeted whole milk yogurt, 1 cup kefir, 1/2 cup whole evaporated, milk
Milk, Low Fat / 2%
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
1 cup (8 oz) 2% low-fat milk, 1 cup fortified soy milk, 3/4 cup (6 oz) plain or artificially sweetened low-fat, yogurt
Milk, Non-Fat / 1%
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
1 cup (8 oz) nonfat or 1% milk, 1 cup fortified reduced-fat soy milk, 2/3 cup (6 oz) plain or artificially sweetened nonfat yogurt
Cheese
Cheese, Regular
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 oz, 1/4 cup shredded or 1 slice of American, cheddar, Monterey Jack, or Swiss Cheese
Cheese, Part-Skim
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 slice or 1 oz or 1/4 cup shredded Mozzerella, Feta, or 2 oz Ricotta cheese
Meats
Meat, High-Fat
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz pork spareribs, 3 oz Polish sausage, pork, 3 oz cooked turkey bacon, 1 (4.5 oz) large hot dog
Meat, Medium Fat
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz cooked boneless pork chops, 3 oz cooked ground lamb, 3 oz cooked turkey bacon
Meat, Lean Fat
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz cooked ground turkey meat, 3 oz cooked beef tenderloin, 3 oz cooked lean boneless pork chops, 3/4 cup 4.5% fat cottage cheese, 3 oz of flank steak or lean ham
Meat Very Lean Fat
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz steamed, boiled or baked shrimp, 3 oz steamed, boiled or baked crab, 3 oz boneless chicken breast without skin, 3 oz boneless light turkey meat roasted, without skin, 3 oz sliced lean lucheon meat
Meat, Organs
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz grilled, baked or broiled liver
Fish High Fat
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz of higher fat fish such as mackerel or salmon
Fish, Other
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3 oz of lean fish such as flounder, haddok, halibut, perch, pike, pollock, sea bass, sole, trout, tuna (fresh or canned in water)
Meat, Replacements or Analogue
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 vegeburger patty such as Griller or Garden burger (VLM)
Eggs
Eggs
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 whole egg
Egg Substitute
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1/4 cup egg substitute, such as Egg Beaters Brand
Beans
Beans or Lentils
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 3/4 cup cooked beans such as pinto beans, black beans, and lentils
Soy
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 4 oz or 1/2 cup tofu, 3 tbsp cooked soybeans or edamame (green soybeans)
Nuts and Fats
Nuts
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 2 tbsp peanut butter, 1 oz nuts such as almonds, walnut halves, or peanuts
Mono Oil
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 2 tbsp or 1/8 slice of a medium avocado, 1 tsp canola, olive or peanut oils, 8 large ripe black olives, 10 green stuffed olives
Other Oil
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 tbsp regular mayonnaise or 2 tsp Miracle Whip salad dressing, 1 tsp corn, safflower, or other salad oils, 1 tbsp regular or 2 tbsp reduced-fat salad dressing, 1 tbsp sunflower or pumpkin seeds
Butter or Lard
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 tsp, pat or 2 tsp whipped butter, 1 slice bacon or 1 tsp lard, 1 tbsp regular cream cheese or sour cream
Margarine, Regular
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 tsp stick margarine
Margarine, Soft
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 1 tsp soft tub margarine or 1 tbsp light (reduced-fat) margarine
Sweets
Sweets or Regular Soda
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 6 oz sugar sweetened soft drink or soda (1, 12 oz. can is equal to 2 servings), 0.3 oz candy such as jelly beans Skittles, 1 oz brownie square, 1 tbsp sugar (Sugar)
Liquids
Alcohol
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 12 oz can of beer, 4.5 oz glass of wine, 1.5 oz hard liquor
Caffeinated Beverages
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 12 oz can of cola, 1 cup coffee, and 1/2 serving energy drink
Water
*Please enter a number (1/4 as .25, 1/2 as .5, 1/3 as .3, etc)
Example: 8 oz or 1 cup of water