Food Acceptance / Fears Survey
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 Try |
|Milk – 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:
_________________________________________________________
_________________________________________________________
_________________________________________________________
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