Diet Questionnaire Form

Download and use this form as a Diet Questionnaire for your patient or customer.

Diet Questionnaire Form

Text Version of this Form

Diet Questionnaire

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?
Yes No

3. Do you add salt to foods during cooking
at the table? Yes No

4. Do you minimize your intake of sweets,
Yes No
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

Yes No
6. Do you limit your intake of saturated
fats (butter, cheese, cream, fatty meats)?

Yes No

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?