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Brief dietary assessment questionnaire

Brief dietary assessment questionnaire
Over the past few months: 0 points 1 point 2 points
  1. How many times a week do you eat fast food meals or snacks?
 Less than one time  One to three times  Four or more times
  1. How many servings of fruit did you eat each day?
 Five or more  Three to four  Two or less
  1. How many servings of vegetables did you eat each day?
 Five or more  Three to four  Two or less
  1. How many regular sodas or glasses of sweet tea did you drink each day?
 Less than one  One to two  Three or more
  1. How many times a week did you eat beans (like pinto or black beans), chicken, or fish?
 Three or more times  One to two times  Less than one time
  1. How many times a week did you eat regular snack chips or crackers (not low-fat)?
 One time or less  Two to three times  Four or more times
  1. How many times a week did you eat desserts and other sweets (not the low-fat kind)?
 One time or less  Two to three times  Four or more times
  1. How much margarine, butter, or meat fat do you use to season vegetables or put on potatoes, bread, or corn?
 Very little  Some  A lot
Summary score (sum of all items) = _____      
Responses in the first points column indicate healthy eating habits (scored 0), responses in the second points column indicate less healthy eating habits (scored 1), and responses in the third points column indicate the least healthy eating habits (scored 2). Summary scores may range from 0 to 16, with lower numbers indicating good dietary habits and higher scores indicating poorer dietary habits.
Reproduced with permission. Copyright © Alice Ammerman. All rights reserved.
Graphic 107808 Version 1.0

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