Food Frequency Survey

Lifestyle Medicine Group

Name

First M.I. Last

Date of Birth  

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


Grains and Starches


Refined Grains, Cereals and Breads

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

Example: 1 slice whole grain bread, 1/2 cup cooked oatmeal, whole grain pasta, or cooked brown rice (G and S)

Fruits


Fruits

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

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

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

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%

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%

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

Example: 1 oz, 1/4 cup shredded or 1 slice of American, cheddar, Monterey Jack, or Swiss Cheese

Cheese, Part-Skim

Example: 1 slice or 1 oz or 1/4 cup shredded Mozzerella, Feta, or 2 oz Ricotta cheese

Meats


Meat, High-Fat

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

Example: 3 oz cooked boneless pork chops, 3 oz cooked ground lamb, 3 oz cooked turkey bacon

Meat, Lean Fat

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

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

Example: 3 oz grilled, baked or broiled liver

Fish High Fat

Example: 3 oz of higher fat fish such as mackerel or salmon

Fish, Other

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

Example: 1 vegeburger patty such as Griller or Garden burger (VLM)

Eggs


Eggs

Example: 1 whole egg

Egg Substitute

Example: 1/4 cup egg substitute, such as Egg Beaters Brand

Beans


Beans or Lentils

Example: 3/4 cup cooked beans such as pinto beans, black beans, and lentils

Soy

Example: 4 oz or 1/2 cup tofu, 3 tbsp cooked soybeans or edamame (green soybeans)

Nuts and Fats


Nuts

Example: 2 tbsp peanut butter, 1 oz nuts such as almonds, walnut halves, or peanuts

Mono Oil

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

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

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

Example: 1 tsp stick margarine

Margarine, Soft

Example: 1 tsp soft tub margarine or 1 tbsp light (reduced-fat) margarine

Sweets


Sweets or Regular Soda

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

Example: 12 oz can of beer, 4.5 oz glass of wine, 1.5 oz hard liquor

Caffeinated Beverages

Example: 12 oz can of cola, 1 cup coffee, and 1/2 serving energy drink
Water

Example: 8 oz or 1 cup of water