Food Frequency Survey

Nutrition Counseling Services

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