FOOD QUESTIONNAIRE - DIALYSIS. Copyright Nutritionquest

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1 FOOD QUESTIONNAIRE - DIALYSIS RESPONDENT ID # Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec. HOW OFTEN, on average, did you eat the food during the past three months? *Please DO NOT SKIP any foods. Mark "Never" if you didn't eat any of the food in the question.. HOW MUCH did you usually eat of the food? *Sometimes we ask how many you eat, such as egg, eggs, etc., ON THE S YOU EAT IT. *Sometimes we ask "how " as A, B, C or D. LOOK AT THE ENCLOSED PICTURES. For each food, pick the picture (s or plates) that looks the most like the serving size you usually eat. (If you don't have pictures: A=/ cup, B=/ cup, C= cup, D= cups.) EXAMPLE: TO'S DATE YEAR ABOUT THIS SURVEY This form is about the foods you usually eat. It will take about - minutes to complete. Please answer each question as best you can. Estimate if you aren't sure. USE ONLY A NO. PENCIL. Fill in the circles completely, and erase completely if you make any changes. Please write your name in this box. INSTRUCTIONS SEX Male Female There are usually two kinds of questions to answer for each food: ABOUT YOU If female, are you pregnant or breast feeding? No Yes Not female AGE This son drank apple juice twice a week, and had one glass. Once a week he ate a "C"-sized serving of rice (about cup). WEIGHT pounds This form may not be used or reproduced without mission. Please call -- for reprints HEIGHT ft. in. Apple juice Rice HOW OFTEN IN THE PAST THREE S in the PAST NEVER S HOW MUCH ON THOSE S many glasses D Block Dialysis. NutritionQuest PLEASE DO NOT WRITE IN THIS AREA Phone -- SERIAL #

2 This section is about your usual eating habits in the past months or so. This includes all meals or snacks, at home or in a restaurant or carry-out. We will ask you about different TYPES (low-fat, low-carb) at the end of the survey. Include all types (like low-fat, sugar-free). Later you can tell us which type you usually eat. Breakfast sandwiches with eggs, like Egg McMuffins Egg whites or egg substitutes Other eggs like scrambled, boiled or omelets (not egg substitutes) Breakfast sausage, including in sausage biscuits, or in breakfast sandwiches Bacon Pancakes, waffles, French toast or Pop Tarts Cooked cereals like oatmeal, grits or cream of wheat Cold cereals, ANY KIND, like corn flakes, fiber cereals, or sweetened cereals Milk or milk substitutes on cereal Cream cheese Cottage cheese, ricotta cheese Other cheese, sliced cheese or cheese spread, including on sandwiches Grapes, plums, tangerines Bananas Prunes, prune juice, raisins, dates Apples Oranges Fresh peaches, fresh pears Apricots, nectarines Cantaloupe, mango, papaya Applesauce, fruit cocktail, or canned pears, canned peaches Strawberries or other berries - in the PAST NEVER S HOW MUCH ON THOSE S many sandwiches in a day many eggs a day many pieces many pieces many pieces many slices many many many eggs a day many many tablespoons B C / / / This form may not be used or reproduced without mission. Please call -- for reprints D Watermelon Broccoli, cauliflower Carrots, or mixed vegetables with carrots D Corn PAGE

3 - in the PAST NEVER S HOW MUCH ON THOSE S Green beans, wax beans Green peas, snow peas Spinach, or greens like collards, turnip greens, mustard greens Summer squash, zucchini, asparagus Brussels sprouts, okra, artichokes Avocado, chili pep Sweet potatoes, yams, winter squash, sweet potato pie, pumpkin pie French fries, home fries, hash browns Potatoes not fried, including mashed, boiled, baked, instant, or potato salad Cole slaw, cabbage, Chinese cabbage Green salad, lettuce salad Raw tomatoes, tomato juice, V- juice Salad dressing, any kind, regular or low-fat Refried beans or bean burritos Pinto beans, black beans, chili with beans, baked beans Bean soup, lentil soup, pea soup Vegetable soup, vegetable-beef soup, or tomato soup Any other soup including chicken noodle, cream soups, Cup-A-Soup, ramen Pizza Spaghetti, lasagna or other pasta with tomato sauce Macaroni and cheese Other noodles like egg noodles, pasta salad, sopa seca Tofu or meat substitutes like veggie burgers, veggie chicken, vegetarian hot dogs or vegetarian lunch meats many tablespoons many slices Do you ever eat chicken, meat or fish? Yes No IF NO, SKIP TO BREADS ON NEXT PAGE many patties or dogs D D of the beans This form may not be used or reproduced without mission. Please call -- for reprints D D / cup / cup / cup D D D Hamburgers, cheeseburgers, at home or in a restaurant Hot dogs, or sausage like Polish, Italian or chorizo many hotdogs sm lrg PLEASE DO NOT WRITE IN THIS AREA SERIAL # PAGE

4 Lunch meat like bologna, sliced ham, turkey bologna, or any other lunch meat Steak, roast beef, meatballs, meat loaf, or beef in frozen dinners or sandwiches Tacos Burritos, enchiladas, tamales, with meat or chicken Ribs, spareribs Pork chops, pork roasts Veal, lamb, deer meat Pigs feet, neck bones, oxtails, tongue Menudo, pozole, caldo de res, sancocho, ajiaco Any other beef or pork dish, like beef stew, beef pot pie, corned beef hash, Hamburger Hel Fried chicken, including chicken nuggets, wings, chicken patty Roasted or broiled chicken or turkey Any other chicken dish, like chicken stew, chicken with noodles, chicken salad, Chinese chicken dishes Shellfish like shrimp, scallops, crabs Tuna, tuna salad, tuna casserole Fried fish or fish sandwich Other fish, not fried BREADS Biscuits, muffins, croissants (not counting breakfast sandwiches with eggs) Hamburger buns, hotdog buns, hoagie buns, submarines Bagels, English muffins, dinner rolls Tortillas (not counting those eaten in tacos or burritos) Corn bread, corn muffins, hush puppies Any other bread or toast, including white, dark, whole wheat, and what you have in sandwiches Rice, or dishes made with rice Margarine (not butter) on bread or on vegetables Butter (not margarine) on bread or on vegetables - in the PAST NEVER S HOW MUCH ON THOSE S many slices D many many many medium pieces pcs/ nugts of the tuna many many many in a day many pieces in a day many slices in a day A B B C C sm med This form may not be used or reproduced without mission. Please call -- for reprints many / D D / in a day many pats (tsp) many pats (tsp) D D / PAGE

5 - in the PAST NEVER S HOW MUCH ON THOSE S Protein bars, like Power Bars, Clif Bars, Balance, Luna, Atkins bars many Peanuts or peanut butter Potato chips, any kind Other snack chips like tortilla chips, Fritos, Doritos, popcorn (not pretzels) Crackers, like Saltines, Cheez-Its, or any other snack cracker Jelly, jam Mayonnaise, sandwich spreads Catsup, salsa or chile peps Mustard, barbecue sauce, soy sauce, gravy, other sauces Donuts Cake, or snack cakes like cupcakes, Ho-Hos, Entenmann's, or any other pastry Cookies, Graham crackers, or granola bars Ice cream, ice cream bars, milk shake, yogurt, frozen yogurt many tablespoons many tablespoons many many pieces many / / sm med Jello, sherbet or popsicles Pie including fast food pies or many snack pies pieces / Chocolate candy like candy bars, M&Ms, Reeses Any other candy, not chocolate, like hard candy, Lifesavers, Skittles, Starburst, in a day jelly beans Glasses of milk (any kind, including soy), not counting on cereal or coffee Low-protein drinks like Suplena, Resource, Re/Gen LP Higher-protein drinks like NovaSource, Nepro, Re/Gen HP Drinks like Boost, Ensure, SlimFast, Sego, Slender Real % orange juice. Don't count orange soda or Sunny Delight Apple juice, grape juice, pineapple juice, or % juice blends Cranberry juice or cocktail, Hawaiian Punch, Hi-C, Tang, Sunny Delight Drinks with some juice, like real lemonade, Knudsen, Fruitworks - - in the PAST NEVER S - - many tablespoons / mini med lrg king - pcs / pkg pkg HOW MUCH on the days you drink it? many -OZ many -OZ CANS many -OZ CANS many -OZ CANS / many many many -OZ many -OZ D many tablespoons / This form may not be used or reproduced without mission. Please call -- for reprints D D / / / / / / / PAGE

6 Kool-Aid, instant lemonade or instant tea, or Snapple-type beverages - in the PAST NEVER S HOW MUCH on the days you drink it? IN A - ounces -ounce bottle can cans Soft drinks, not cola type, like ginger ale, -Up, Sprite, orange soda, root beer, regular or diet IN A - ounces -ounce bottle can cans Other soft drinks, like Coke, Pepsi, Dr. Pep, Gatorade, Mountain Dew IN A - ounces -ounce bottle can cans Beer, wine or any other alcoholic drink Glasses of water, tap or bottled Coffee, tea, herbal tea Nondairy creamer in coffee or tea Milk or cream in coffee or tea Sugar or honey in coffee or tea About how many servings of vegetables do you eat, day or week, not counting salad or potatoes? About how many servings of fruit do you eat, not counting juices? often do you use fat or oil in cooking? Milk Whole milk Reduced-fat % milk Low-fat % milk RARELY many DRINKS many - + many CUPS + many tbsp/day + many tbsp/day + many tsp/day + If you eat the following foods, what type do you usually eat? MARK ONLY ONE ANSWER FOR EACH QUESTION Non-fat milk Soy milk Non-dairy creamer / Nut milk or VitaMite Rice milk Don't drink Cola-type soda or pop Diet soda, low-calorie Regular Don't drink This form may not be used or reproduced without mission. Please call -- for reprints Non-cola-type soda or pop Diet soda, low-calorie Regular Don't drink Hamburgers or cheeseburgers Hamburgers Cheeseburgers Don't eat Hot dogs Low fat or turkey dogs Regular hot dogs Don't eat Lunch meats Low-fat or turkey lunch meats Regular lunch meats Don't eat + Spaghetti or lasagna Meatless With meat sauce or meatballs Don't eat Cheese Low Fat Not Low Fat Don't eat / PLEASE DO NOT WRITE IN THIS AREA SERIAL # PAGE

7 If you eat the following foods, what type do you usually eat? MARK ONLY ONE ANSWER FOR EACH QUESTION Salad dressing Low-Carb Low-fat Regular Don't use Bread % whole wheat Regular Don't eat Tortillas Corn Flour Don't know or don't eat Beef or pork Avoid eating the fat Sometimes eat the fat Often eat the fat Don't eat Chicken or Turkey Avoid eating the skin Sometimes eat the skin Often eat the skin Don't eat What kinds of fat or oil do you usually use in cooking? MARK ONLY ONE OR TWO Don't know, or Pam Butter Butter/margarine blend Stick margarine Soft tub margarine Low-fat margarine Corn oil, vegetable oil Olive oil or canola oil Lard, fatback, bacon fat Crisco If you eat cold cereals, what do you eat? Choose one or two that you eat most often. (If you usually just eat one kind, just choose one.) Low-carb cereals like Atkins Cheerios, Grape Nuts, Shredded Wheat, Wheaties, Wheat Chex Total Fiber One Product, Complete All Bran, Bran Buds Other fiber cereals like Raisin Bran, Fruit-n-Fiber Sweetened cereals like Frosted Flakes, Froot Loops Other cold cereals, like Corn Flakes, Rice Krispies, Special K What vitamin supplements do you take fairly regularly? Multiple Vitamins. Did you take... Prescription multiple vitamins for dialysis patients, like Nephro-Vite, Dialyvite, Diatx Zn, NephPlex Other multiple vitamins like Once-A-Day, Centrum, Theragran, senior vitamins or house brands of multiple vitamins Stress-tabs or B-Complex type Single Vitamins, not part of multiple vitamins Vitamin A (not beta-carotene) Beta-carotene Vitamin C Vitamin E Folic Acid, Folate Calcium, Tums or Phoslo Vitamin D, alone or combined with calcium Zinc Iron Selenium Omega-, fish oil, flax seed oil DIDN'T TAKE HOW OFTEN A FEW S - S - S FOR HOW MANY YEARS? LESS THAN YEAR YEAR YEARS - YEARS This form may not be used or reproduced without mission. Please call -- for reprints - YEARS + YEARS If you took Once-a-day, Centrum or Thera-type multiple vitamins, did you usually take types that contain minerals, iron, zinc, etc. do not contain minerals Don't know If you took vitamin C, how many milligrams of vitamin C did you usually take, on the days you took it? + Don't know If you took vitamin E, how many IUs of vitamin E did you usually take, on the days you took it? + Don't know PAGE

8 SOME LAST QUESTIONS ABOUT YOU Would you say your health is Excellent Very good Good Fair Poor Do you smoke cigarettes now? Yes No IF YES, On average about how many cigarettes a day do you smoke now? Are you Hispanic or Latino Not Hispanic or Latino What race do you consider yourself to be? (MARK ALL THAT APPLY) White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Do not wish to provide this information In the past three months how do you rate your appetite? Select only one. Very good Good Fair Poor Very poor Have you had a change in appetite in the past three months? Select only one. My appetite increased My appetite has NOT changed My appetite decreased is your chewing or swallowing, and how are your teeth? Select only one. I have no chewing problems (good dental status) I have some chewing problems and/or a few missing teeth Many of my teeth are missing often do you eat meals away from home or nursing home? Select only one. Almost never to times week Once a month or less More often (Usually) to times week If you are asked to follow a low potassium diet, do you think you are following it? I am not asked to follow a low potassium diet I try to follow a low potassium diet and I usually do I try to follow a low potassium diet but I don t always follow it I don't follow a low potassium diet Don't know If you are asked to follow a low phosphorus diet, do you think you are following it? I am not asked to follow a low phosphorus diet I try to follow a low phosphorus diet and I usually do I try to follow a low phosphorus diet but I don t always follow it I don't follow a low phosphorus diet Don't know All of my teeth are missing I cannot chew or swallow at all This form may not be used or reproduced without mission. Please call -- for reprints EM--: Thank you very for filling out this questionnaire. Please take a minute to go back and fill in anything you may have skipped. PLEASE DO NOT WRITE IN THIS AREA SERIAL # PAGE