Download and use this form as a Diet Questionnaire for your patient or customer.
Text Version of this Form
The following questionnaire is designed to increase your knowledge and awareness of your
overall diet, and to highlight potential areas of concern.
1. Do you drink enough fluids so that Yes No
your urine is a pale yellow color?
2. Do you try special or fad diets?
3. Do you add salt to foods during cooking
at the table? Yes No
4. Do you minimize your intake of sweets,
especially candy and soft drinks, and
avoid adding sugar to foods?
5. Is your diet well-balanced (including
vegetables, fruits, breads, cereals, dairy Yes No
products, and adequate sources of
6. Do you limit your intake of saturated
fats (butter, cheese, cream, fatty meats)?
7. Do you limit your intake of cholesterol
(eggs, liver, meats)?
8. Do you eat fish and poultry more often Yes No
than red meats?
9. Do you eat high-fiber foods (vegetables, Yes No
fruits, whole grains) several times at day?