The Campus Recreation Department Fitness & Wellness Program

Nutrition Questionnaire

The assessment of nutrition involves looking at four key dietary factors: 1) Prudent diet habits referring to
general nutrition balance, 2) Calorie control habits pertaining to weight loss and gain,
3) Dietary fat referring to habits that affect cholesterol in the diet, and 4) Sodium or salt control which affects
blood pressure. All four of these dietary factors have an influence as to whether or not your diet contributes to
an unusual risk of heart disease. Complete the questionnaire below to get an idea of where you stand.
Answer each question according to your usual eating habits. Place the number corresponding to your answer in
the space provided to the left of each question. Total these numbers at the end of each category.
PRUDENT DIET
_____ How much low fat or skim milk, yogurt, and low fat cheese do you consume in a typical day?
1. 16 ounces of low fat milk or yogurt and 2 ounces of low fat cheese per day.
2. 8 ounces of low fat milk or yogurt and 1 ounce of low fat cheese per day.
3. Only use milk on cereal, seldom eat low fat cheese or yogurt.
4. Do not consume low fat milk, yogurt, or cheese at all.
_____ How often do you choose to eat potato chips, corn chips, taco chips, olives, nut or similar foods as
snacks or with a meal?
1. Never or rarely (less than 1X/week)
3. 3-4 times per week
2. Occasionally (1-2 times per week)
4. 5 or more times per week
_____ How many servings of fruit do you eat per day?
1. 4 or more
2. 2-3

3. 1-2
4. None

_____ How many servings of whole grain breads and cereals, rice, and pasta do you eat each day?
1. 6 or more
3. 3-4 servings
2. 5
4. Less than 3
_____ Which describes your consumption of vegetables?
1. Snack on raw vegetables and eat vegetables/salads with most meals
2. Dont snack on vegetables but eat salads and vegetables with meals often
3. French fries comprise the majority of my vegetable intake
4. Rarely eat vegetables
_____ How many 8 ounces glasses of water do you drink in a day? (You may count other beverages as water,
provided they do not contain caffeine or alcohol).
1. 8 or more glasses
3. 2-4 glasses
2. 5-7 glasses
4. One glass or none

_____ TOTAL - PRUDENT DIET

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CALORIE CONTROL
_____ What most closely describes the amount you eat at a time?
1. Stop eating when full, even if there is still food on the plate.
2. Select a small amount and clean the plate
3. Eat what is served and clean the plate
4. Take second helpings, especially when it tastes good.
_____ If you wanted to decrease your calorie intake, which would you do?
1. Cut down on meat, sauces, gravy, desserts, and salad dressings and limit portion sizes
2. Continue to eat the same foods but limit portion sizes
3. Leave off bread and potatoes
4. Follow a crash diet for a few days
_____ How many alcoholic beverages do you consume?
1. 0-2 drinks per week
2. 3-5 drinks per week

3. 6-12 drinks per week

_____ Do you ever eat until you are so full that you are uncomfortable?
1. Rarely or never
2. Periodically, 1-2 times a month
3. Regularly, once a week
4. Often, every couple of days
_____ How often do you eat sweets (candy, pastry, cookies, desserts, ice cream, sugar-based beverages) do
you eat?
1. Once a week or less
2. A few servings per week
3. 1-2 servings per day
4. My diet consists mostly of sweets
_____ Which pattern of eating typifies your style?
1. Regular meals at frequent intervals
2. Occasionally skipping a meal/or bingeing
3. Eating regularly for a few days, then bingeing when there is time to relax
4. Skipping meals during the day and eating all evening

_____ TOTAL - CALORIE CONTROL

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FAT CONTROL
_____ How many eggs (including yolks) do you eat per week?
1. 0-2
3. 6-8
2. 3-5
4. More than 8
_____ How many times per week do you consume red meat (beef steak, Canadian bacon, lamb, ribs)?
1. 0-2 times
3. 5-6 times
2. 3-4 times
4. 7 or more
_____ When you prepare or eat poultry (chicken, turkey, Cornish hen) which of the following plans do you
most closely follow?
1. Choose white meat, remove skin and prepare by baking or broiling
2. Choose dark meat, skin removed and bake or broil
3. Bake or broil, skin on and serve with gravy
4. Leave the skin on and fry
_____ When selecting a salad or sandwich, which of the following fillings would you choose most often?
1. Lentils, kidney beans, peas, pinto or garbanzo beans
2. Turkey, chicken, tuna, other lean meats, low fat cheese
3. Same as below, but without cheese
4. Ham, pastrami, hamburger, salami, frankfurter, bacon, with cream or hard cheese
_____ When eating dairy products (milk, yogurt, ice cream, cheese) do you select?
1. Only skim or low-fat products
2. Only look for low-fat products except when selecting ice cream
3. Are not aware of the difference
4. Only enjoy whole fat content dairy products
_____ If you were having potatoes, which would you choose?
1. Boiled or baked with no added fat
2. Boiled or baked with liquid margarine or yogurt
3. Boiled or baked with hard margarine/butter and sour cream
4. French fried or hash browns

_____ TOTAL- FAT CONTROL

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SODIUM CONTROL
_____ How frequently do you add salt to your food after it is served at the table?
1. Never
3. Once a day
2.1-2 times per week
4. With almost every meal
_____How frequently do you eat the following high-sodium foods: hot dogs, bologna, bacon, ham, sausage?
1. Rarely or never
3. Canned without sauces
2. 1-2 times per week
4. Canned, frozen or dry with sauces and /or seasonings
_____ In what form do you most frequently purchase food for meal preparation?
1. Fresh
3. Canned without sauces
2. Canned or frozen without salt
4. Canned, frozen or dry with
sauces and or Seasonings
_____ While preparing meals or when eating out, how frequently do you add any or all of the following items
to your food? Mustard, pickles, relish, soy sauce, ketchup, meat tenderizer, MSG?
1. Rarely or never
2. 1-2 times per week
3. 3-4 times per week
4. Daily
_____ How often do you use canned soups or dry soup/broth mixes?
1. Rarely or never
2. 1-2 times per week
3. 3-4 times per week
4. Daily
_____ How many prepackaged box dinners (e.g. Healthy Choice, Weight Watchers, Michelinas) or frozen
pizzas do you consume each week?

_____ TOTAL-SODIUM (SALT) CONTROL

The Campus Recreation Department Fitness & Wellness Program

PRUDENT DIET
(Number Score)
(Score Result)

Score Results for Each Section

Excellent
Good
Fair
Poor
Very Poor

6-8
9-12
13-16
17-20
21-24

FAT
(Number Score)
(Score Result)

SODIUM
(Number Score)
(Score Result)

BASIC DIET GUIDELINES

58% Carbohydrate
30% Fat
12% Protein
Carbohydrate has 4 kcal/gram
o 10% simple - fruits, vegetables, sweets
o 48% complex - grains, pasta, potatoes
9 Fat has 9 kcal/gram
o 10% saturated - solid, from animal sources
<1% trans fat
o 20% unsaturated - liquid, from plant sources
o exceptions - palm & coconut oil & cocoa butter are liquid but contain very high
amounts of saturated fat
9 Protein has 4 kcal/gram

The Campus Recreation Department Fitness & Wellness Program

Improve your score in each nutrition category by incorporating these strategies into your lifestyle. Select
three strategies from each of the lists below and improve your nutrition rating to excellent. Place an X next to
those you would like to adopt. If you scored in the good or excellent category, only one or two strategies need to
be targeted.
Prudent Diet Strategies
Drink 6-8 glasses of water each day
Drink less regular soda, coffee, and sweetened tea
Consume at least 2 servings of low-fat dairy products each day
Eat more dark green and deep yellow-orange fruits and vegetables (i.e. spinach, greens, broccoli, carrots,
cantaloupe, peaches, yams)
Include a good source of vitamin C daily (i.e. oranges, grapefruit, tomatoes, or juices from these fruits)
Select whole grain breads and cereals, including bran products, over their refined counterparts more often
Eat fresh or raw fruits and vegetables whenever possible
Calorie Control Strategies
Limit intake of sweets (i.e. candy, cookies, syrup, jelly, desserts, pastries, donuts, and sweet rolls)
Cut down on alcohol consumption
Refuse second helpings
Take smaller portions
Stop eating when you are full
Cut down on toppings and condiments (sweet and high fat additions)
Avoid high fat and junk foods (see section on STRATEGIES FOR REDUCING FAT)
_____ Eat at regular intervals to avoid allowing yourself to get too hungry and overeat at your next meal/snack
Strategies for Reducing Fat
Limit intake of beef and pork to three servings per week
Eat more fish, skinless poultry and non-meat protein sources (such as beans, eggs, and nuts)
Select low-fat dairy products ( i.e. skim milk, low fat yogurt, sherbert, frozen yogurt, low fat cottage
cheese)
Reduce intake of egg yolks
Avoid high-fat toppings and condiments (i.e. butter, margarine, cream, sour cream, non-dairy creamers,
salad dressings, guacamole, gravy, sauces)
Avoid fried foods
Choose baked, broiled, boiled, steamed, poached, and marinated foods
Remove visible fat from meat and skin from poultry
Limit intake of butter and margarine
Strategies for Reducing Sodium (Salt)
Eliminate salt at the table and avoid salt in cooking
Cut down on use of high-sodium condiments (i.e. mustard, ketchup, pickles, relish, soy sauce, steak sauce,
MSG, and meat tenderizers)
Avoid fast food restaurants
Rarely eat convenience foods (i.e. canned soups, dried soup mixes, TV dinners, boxed prepared foods)
Substitute raw fruits and vegetables for processed snacks and spreads (i.e. chips, nuts, dips, cheese spreads,
pretzels, and crackers.)

The Campus Recreation Department Fitness & Wellness Program

Name ____________________________________________

Note: Please bring this completed 3-day food record to your first appointment.
Instruction for completing food records: On the attached form, please record everything that you eat and drink
for three days. Record everything (brand names, serving size, how it was prepared). Please be honest and try
not to change the way you eat simply because you are writing everything down. A true record of how you eat is
what we are looking for and will help us give you the best feedback possible.
Date

Food/Beverage

Amount

The Campus Recreation Department Fitness & Wellness Program

Date

Food/ Beverage

If you need additional space, attach a piece of paper and continue to record.
How much do you think recording your intake affected what you ate?
A lot
Some
A little
Not much at all

Amount