Food Acceptance Survey
Name:
Check the box or boxes which best describe your relationship with each food:
Dairy Proteins: / Like / Don’t Like / When last tried this food / Would TryMilk – White
Milk – Chocolate
Soy Milk
Cheese (melted)
Cheese (hard)
Cottage Cheese
Mozzarella Cheese (Cheese sticks)
Pudding
Smoothies
Yogurt – Blended
Yogurt – With fruit
Bean/Meat Proteins: / Like / Don’t Like / When last tried this food / Would Try
Chicken
-Baked
-Nuggets
-Grilled
Turkey
-Turkey (Deli-style)
-Breast
Beef
-Ground
-Roast Beef
-Steak
Pork
-Chops
-Ham (Deli-style)
-Loin
-Sausage
-Bacon
Clams, Crabs, Shrimp
Fish
-Baked
-Grilled
-Fish Sticks
Baked Beans
Legumes (Beans & Peas)
Tofu – Raw
Tofu – Cooked
Eggs – Scrambled
Eggs – omelet or baked
Eggs – Fried
Nuts (almonds & walnuts)
Fruit: / Like / Don’t Like / When last tried this food / Would Try
Avocado
Apple
Applesauce
Banana
Blueberries
Blackberries
Strawberries
Cantaloupe
Watermelon
Cherries
Grapefruit
Grapes
Mango
Kiwi
Orange
Pear
Pineapple
Plums
Fruit Juice
Vegetables – Cooked: / Like / Don’t Like / When last tried this food / Would Try
Asparagus
Beets
Broccoli
Cabbage
Cauliflower
Eggplant
Mushrooms
Peas
Sugar Snap Peas
Sauerkraut
Spinach
String Beans
Tomatoes
Tomato sauce (pizza/pasta sauce)
Carrots
Zucchini
Potatoes – Baked
Potatoes – Mashed
Potatoes – Red/White - Boiled
Vegetables – Raw:
Broccoli
Red Cabbage
Carrots
Cauliflower
Celery
Cucumbers
Sugar Snap Peas
Lettuce
Mushrooms
Mustard Greens
Peas
Radishes
Spinach
String Beans
Tomatoes
Zucchini
Salad (Garden, Caesar, etc.)
Grains: / Like / Don’t Like / When last tried this food / Would Try
Oatmeal
Cold Cereal (please specify)
Pancakes, Waffles, French Toast
Bagel – Toasted
Bagel – Untoasted
Bread (whole, wheat, rye, white)
Bread – Toasted
English Muffin
Stuffing
Pasta – Hot
Pasta – Cold
Pasta – With Sauce
Pasta – With Butter
Tortilla
Crackers
Noodles
Brown Rice
White Rice
Cakes/Pies
Doughnuts
Cookies
Chips
Fast Foods, French Fries
Fats/Condiments: / Like / Don’t Like / When last tried this food / Would Try
Salad Dressing
Butter
Mayonnaise
Ketchup
Mustard
Sour Cream
Miscellaneous:
Pizza
Hot Dogs
Hamburgers
Grilled Cheese
Soup
Macaroni and Cheese
Other:
Eating Behaviors and Daily Habits
Please circle appropriate answers to the following questions (parents – tell us about your child):
1.) How often do you use the bathroom for a bowel movement?
2+ times/day Once a day 4-5 times/week 2-3 times/week
2.) How often are you active/exercise?
Once a day 4-5 times/week 2-3 times /week Once/week
3.) How often do you have meals as a family?
Every day 4-5 times/week 2-3 times/week Once/week
4.) How often do you have meals by yourself?
Most meals Some meals Occasionally
5.) How often do you eat your meals at the table?
Most meals Some meals Occasionally
6.) How often do you eat your meals “on-the-go?”
Most meals Some meals Occasionally
7.) What is your reaction to new foods?
Refusal Will try, but typically rejects Open to trying
8.) How many foods are currently considered to be “acceptable foods” and used in regular rotation for meals?
20+ 10-20 Less than 10
9.) Do you eat “snacks” during the day? If so, how often?
4+ 2-3 times Usually only once
Please answer the following for yourself and/or your child as appropriate:
10.) Are you and/or your partner currently on a diet or counting calories?
______
11.) Do you skip meals?
______
12.) How often during the week do you cook meals at home?
______
13.) What are the current consequences if your child refuses their meal?
______
14.) Has your child ever coughed or gagged after trying a new food?
______
15.) Has your child ever had any difficulty swallowing any foods? If so, which ones?
______
16.) How old was your child when “picky eating” behavior began?
______
17.) Have you taken your child to a behavioral or occupational therapist for
any reason? If so, please briefly describe the outcome.
______
______
______
18.) Please describe prior strategies in your home that you used to encourage
your child to eat their meals that were successful:
______
______
______
19.) Please describe prior strategies in your home that you used to encourage
your child to eat their meals that were NOT successful:
______
______
______
20.) Please list any GI issues that have been diagnosed:
______
______
______
21.) Please list any food allergies that have been diagnosed:
______
______
______
DM-2013