Nutrition Questionnaire

Do you read ingredient labels to avoid added sugars and syrups before deciding on an item?
    All the time0
    Most of the time1
    Some of the time4
    Never7
How many servings (1 serving is approximately 1 handful) of fruits and vegetables do you eat a day, on average? Do not count juice or dried fruits.
    0–17
    2–33
    ≥40
Do you avoid saturated fat? (Saturated fat is found in all 4-legged animal products [eg, cows/pigs], 2-legged animal skin [eg, chickens], and packaged or baked foods with butter, margarine, lard, palm, coconut, or cottonseed oils.)
    All of the time0
    Most of the time2
    Some of the time5
    Never7
How many servings (1 serving is approximately 1 handful) of processed meat do you eat in a typical week (items include bacon, sausage, ham, hot dogs, deli meats, and others)?
    1–21
    3–44
    ≥58
When eating grains such as rice, bread, cereal, and pasta, what percentage of them are 100% whole grain?
    None7
    Some5
    Most3
    All0
How many days a week do you eat breakfast?
    0–17
    26
    35
    44
    53
    62
    71
How many days a week do you eat fried foods or foods with partially hydrogenated oils (think margarine, cookies, cake, crackers)?
    0–10
    2–34
    4–66
BMI (kg/m2)*
    19–27A
    <19B
    >27-31C
    >31-35D
    >35E
Scoring for eating habits
    Good
        Score: 0–10 and BMI in category A
        Smartset recommendations: consult to GO! Foods for You, Good Eating Habits educational handout
    Fair
        Score: 11–20 and BMI in category A or <20 and BMI in category B or C
        Smartset recommendations: consult to nutrition therapy, consult to GO! Foods for You, Fair Eating Habits educational handout
    Poor
        Score: >20 and BMI in any category or >1 and BMI in category D or E
        Smartset recommendations: consult to nutrition therapy, consult to GO! Foods for You, Poor Eating Habits educational handout

  • ↵* Body mass index (BMI) data from the electronic medical record.