| Food Item | Yes | No |
| Fish: I ate 3 - 4 servings this week |
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| Fruit: I ate 3 - 4 servings every day this week |
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| Vegetables: I ate 3 - 4 servings every day this week |
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| Whole grains: I ate 1 - 3 servings every day this week |
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| Legumes: I ate 1 - 3 servings every day this week |
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| Red meat: I ate less than 1 or 2 servings every day this week |
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| Dairy: I ate less than 1 - 2 servings every day this week |
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| Poultry/eggs: I ate less than 1 - 2 servings every day this week |
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| Total: |
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