Total Diet Recall Questionnaire

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Total Diet Recall Questionnaire

Part I. Food   (circle yes or no)

Finish the sentence, I eat:

Fruits and vegetables every day                  Yes   No

Sweets less than twice a week                    Yes   No

Breakfast daily                                  Yes   No

Fish at least twice times week                   Yes   No

Whole grains at least five times a week          Yes   No

Soy foods (tofu and soybeans) twice a week       Yes   No

Red meat less than twice a week                  Yes   No

Organic foods every day                          Yes   No

Beans and legumes at least five times a week     Yes   No

A handful of nuts every day                      Yes   No


Part II. Beverages (circle yes or no)

Finish the sentence, I drink:

Water throughout the day                         Yes   No

Plain coffee every day (no more than 3 8-ounce   Yes   No

A glass of fruit juice every day (1 glass =      Yes   No
4 oz.)

Not more than 1 to 2 glasses of alcohol daily    Yes   No

Milk shakes occasionally                         Yes   No

Regular soda less than twice a week              Yes   No

Mineral water daily                              Yes   No

Fruit shakes at least three times a week         Yes   No

Green tea daily                                  Yes   No

Diet soda less than once per day                 Yes   No


Total Diet Score Card                            ____  ____

Tally your score by counting up the number of yes's and no's. If you have more yes's, you have a balanced diet filled with real, whole foods and make room for small indulgences. If you have more no's, you should evaluate your overall diet and try to incorporate more nutrient-rich foods into your day.

Courtesy of The Essential Guide to Healthy Healing Foods by Victoria Shanta Retelny, RD, LDN.

Total Diet Recall Questionnaire_VSR

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