Food Frequency Questionnaire

Transcription

1 ID Number Jan Feb Mar Apr May Jun Jul Aug Sep Oct v Dec Today's Date MONTH YEAR PLEASE PROVIDE: PLEASE DO NOT WRITE IN THIS AREA [SERIAL] Food Frequency Questionnaire

2 - - Use a. pencil only. Do not use ink, ballpoint, or felt tip pens. Make solid marks that fill the response completely. Erase cleanly any marks you wish to change. Make no stray marks on this form. MARKING INSTRUCTIONS CORRECT MARK: INCORRECT MARK: The first section of this questionnaire is about your usual eating habits, as an adult, before one year ago and not including any recent dietary changes. Please include foods that you ate in a restaurant. FIRST: SECOND: THIRD: Mark the column to show HOW OFTEN, on average, you ate the food. Mark the column to show HOW MUCH you usually ate of each food A "medium" serving is shown for each food, but only as a guideline. A "small" serving is about one-half the medium serving size shown, or less A "large" serving is about one-and-a-half times the medium serving size shown, or more If you did not eat an item or ate it less than once per month, fill in the oval in the first column marked " OR LESS THAN ONCE MONTH." DO NOT LEAVE IT BLANK. When you select this response for a food, it is not necessary to choose a serving size. SAMPLE: TYPE OF FOOD Oranges Red Wine This person eats one large orange about twice a week, and drinks oz. of red wine about five times a week. C C OR LESS THAN ONCE MONTH - MO. HOW OFTEN - HOW MUCH MEDIUM SERVING S M L FOR OFFICE USE ONLY C C medium oz.

3 FRUITS Bananas Apples, applesauce, pears Citrus fruits (oranges, grapefruit, tangerines) Cantaloupe Grapes CEREALS & DAIRY PRODUCTS Fiber cereals (i.e., Raisin Bran, granola, Shredded Wheat) List type: Sweetened cereals (i.e., Frosted Flakes) List type: Milk on cereal Sugar on cereal (white, brown) Breakfast bars, granola bars, power bars Breakfast shakes, diet shakes Pancakes or waffles Eggs Egg substitutes, Egg Beaters, egg whites Cottage cheese TYPE OF FOOD Peaches, apricots, nectarines, plums (fresh in season) Mangoes, papayas Strawberries Other berries (in season) Watermelon (in season) Any other fruit including kiwi, pineapple Canned fruit Dried fruit (raisins, dates, prunes) Other cold cereals (i.e., Corn Flakes, Cheerios) List type: Cooked cereal (i.e., oatmeal, oat bran, grits) List type: Other cheeses and cheese spreads (regular or lowfat) Yogurt, frozen yogurt (regular or lowfat) OR LESS THAN ONCE MONTH - MO. PLEASE DO NOT WRITE IN THIS AREA HOW OFTEN MEDIUM SERVING medium medium or / cup medium / med. / cup medium / medium / cup / cup / cup / cup / cup Tbsp. or prunes cup cup cup cup cup Tsp. serving serving medium egg=small eggs=med / cup / cup slices or ounces oz. container HOW MUCH S M [SERIAL] - - L

4 VEGETABLES (fresh, frozen, or canned, or in restaurants) String beans, green beans Peas Other beans such as baked beans, pintos, kidney (not including soup) Corn Tomatoes Tomato juice Salsa, ketchup, taco sauce Broccoli Cauliflower or brussels sprouts Spinach, cooked Spinach, raw Mustard greens, turnip greens, collards Cole slaw, cabbage Carrots, or mixed vegetables containing carrots Beets Other vegetables (celery, alfalfa, mushrooms) Radishes Rhubarb Green salad Creamy salad dressing, mayonnaise Oil and vinegar salad dressings French fries and fried potatoes Potatoes not fried, including boiled, baked, mashed, and in potato salad Sweet potatoes, yams Summer squash, zucchini, eggplant Winter squash (acorn, spaghetti) Fat added to vegetables, potatoes, etc., check one: Tofu, bean curd Meat substitutes made from soy - - TYPE OF FOOD Butter Margarine Oil OR LESS THAN ONCE MONTH - MO. HOW OFTEN MEDIUM SERVING / cup / cup / cup / cup medium oz. Tbsp. / cup / cup / cup / cup / cup / cup / cup / cup / cup / cup / cup medium bowl Tbsp. Tbsp. / cup medium or / cup / cup / cup / cup pats or Tsp. / cup cup or patty HOW MUCH S M L

5 MEAT, POULTRY, SEAFOOD, AND MIXED DISHES Hamburger, cheeseburger patties Other ground beef including meat loaf, beef burritos, tacos Beef (includes steak, roast, in sandwiches) Pork (includes chops, roast) Bacon, back bacon Fried fish or fish sandwich Gravies Pasta with cheese (such as macaroni and cheese) Pasta salad, other pasta without tomato Pizza Hot dogs TYPE OF FOOD Beef or vegetable stew or potpie with carrots and other vegetables Game meat (venison, elk, pheasant, duck) Liver including chicken livers Sausage (including Italian, German, Polish, breakfast) Fried chicken, chicken nuggets, chicken wings Chicken, turkey (includes roast, barbecue, in sandwiches, and mixed dishes) Fresh fish (baked, steamed) Canned fish (tuna, tuna salad, tuna casserole, salmon, sardines) Seafood (shrimp, crab, lobster, oysters) Pasta, spaghetti with tomato sauce or meat, lasagna Ham, bologna, other lunch meats (regular or made with turkey) Vegetable soups with carrots or tomatoes such as vegetable beef or tomato soup Lentil, pea, and bean soups Chili with beans (with or without meat) Other soups like chicken noodle, mushroom, cup-a-soup, ramen OR LESS THAN ONCE MONTH - MO. HOW OFTEN MEDIUM SERVING medium or oz. cup oz. cup oz. oz. oz. strips or slices breakfast or other sausage large or small pieces oz. oz. or sandwich oz. oz. or / cup pieces or oz. Tbsp. cup cup / cup slice hot dogs slices/ oz. cup cup cup cup HOW MUCH S M L - -

6 SWEETS Ice cream - - TYPE OF FOOD Margarine on bread or rolls Butter on bread or rolls Doughnuts, pastry Pumpkin pie, sweet potato pie Fruit pies Chocolate candy, candy bars Other hard candy OR LESS THAN ONCE MONTH - MO. HOW OFTEN - - PLEASE DO NOT WRITE IN THIS AREA. - + per MEDIUM SERVING BREADS, SNACKS, SPREADS (Please note that the categories for these columns are different.) White bread, French or Italian # slices bread, including sandwiches each time slice Dark bread, such as whole wheat, rye, pumpernickel Bagels, English muffins, hamburger buns Corn bread, corn muffins Biscuits, muffins (including fast foods) Peanuts, peanut butter, other nuts Tortillas Cookies or cake Cream pies, cheese cake Jams or jelly # pieces each time medium Tbsp. pats pats scoop or / cup piece - cookies med slice or /th pie med slice or /th pie med slice or /th pie small bar or gm. pieces Tbsp. HOW MUCH S YOUR SERVING SIZE M [SERIAL] L piece pieces pieces Rice, or dishes made with rice / cup S M L XL Snacks like nachos with cheese, cup or potato skins with topping skin S M L XL Salty snacks, like potato chips, corn chips, popcorn, crackers cup S M L XL - # slices each time medium # each time slices slices slice slices slices XL tort. tort. tort. tort. S M L XL S M L XL S M L XL

7 TYPE OF FOOD OR LESS THAN ONCE MONTH - MO. HOW OFTEN BEVERAGES (Please note that the categories for these columns are different.) Orange juice or grapefruit juice Apple juice, grape juice Prune juice Whole milk (or chocolate whole milk), not including on cereal % milk (or chocolate % milk), % milk, not including on cereal Skim milk, not including on cereal Soy milk Kool-Aid, Hi-C, or other drinks with added vitamin C Snapple, Calistoga, sweetened bottled waters or instant teas Iced tea, not instant (brewed iced tea, sun tea, restaurant iced tea, bottled tea) Water from the tap at home Water from the tap at work Regular soft drinks (not diet soda) Beer White wine Red wine Liquor Coffee, regular Coffee, decaffeinated Hot black tea (Lipton's), not herbal Hot green tea, not herbal n-dairy creamer in coffee or tea Cream (real) or Half-and-Half in coffee or tea Milk in coffee or tea Type (check one): Sugar or honey in coffee or tea Whole %/% Skim PLEASE DO NOT WRITE IN THIS AREA - + MEDIUM SERVING oz. oz. oz. oz. oz. oz. oz. oz. bottle oz. oz. oz. oz. can or bottle oz. can or bottle oz. oz. shot medium cup medium cup medium cup medium cup Tbsp. Tbsp. Tbsp. Tsp. HOW MUCH [SERIAL] YOUR SERVING SIZE S M L oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. oz. - -

8 About how often do you eat the following foods from restaurants or carry-outs? Remember to think about all meals (breakfast, lunch, dinner, or snacks). RESTAURANT FOOD Fried chicken Burgers Pizza Chinese food, Thai, or other Asian food Mexican food Fried fish IN PAST YEAR - TIMES IN PAST YEAR NUMBER OF VISITS LAST YEAR - TIMES IN PAST YEAR - TIMES A MONTH ONCE A WEEK - TIMES A WEEK What kinds of fat do you usually use in cooking (to fry or stir-fry)? (Mark the one you use most often.) What kinds of fat do you usually add to breads, vegetables, potatoes at the table? (Mark the one you use most often.) - - Don't know Lard, fatback, baconfat Butter Crisco shortening Don't add fat Lard, fatback, baconfat Butter Whipped butter Stick margarine Soft tub margarine Low calorie margarine Olive oil or canola oil Crisco shortening Stick margarine Soft tub margarine Low calorie margarine When you ate the following foods, how often did you eat a low-fat or non-fat version of that food? Milk on cereal Cottage cheese Hard cheese and cheese spreads Yogurt, frozen yogurt Ice cream Salad dressing Cake or cookies DO NOT EAT Corn oil or soybean (vegetable oil) Pam or no oil Olive oil or canola oil Corn oil or soybean oil (vegetable oil) ALWAYS LOW-FAT SOMETIMES LOW-FAT EVERY RARELY LOW-FAT

9 How often did you add salt to your food? Seldom Sometimes Often How often did you eat the skin on chicken? I do not eat chicken How often did you eat the fat on meat? I do not eat meat If you drank orange juice, how often did you drink a calcium-fortified brand? Usually Sometimes Rarely Seldom Sometimes Often Seldom Sometimes Often Answer questions regarding your usual eating habits before one year ago. Do not include any recent dietary changes. Did you eat any hamburgers or cheeseburgers? How often were they: Fast food (any method)? Casual dining, family restaurants (Perkins, Applebee's)? Pan-fried? Grilled/barbecued? Oven-broiled? Microwaved? Medium rare Medium Don't know When you ate hamburgers (or cheeseburgers), how did you usually eat them? (Mark only one.) Rare OR / OF Medium well / OF Well done / OF Very well done ALWAYS OR ALWAYS Don't know - -

10 Did you eat any steak? - - How often were they: When you ate steak, how did you usually eat it? (Mark only one.) Rare Did you eat any chicken? Fast food? Casual dining, family restaurants? Pan-fried? Grilled/barbecued? Oven-broiled? Did you eat any fish or seafood? Medium rare How often was the chicken (including nuggets) you ate: Deep fat fried/fast food? Casual dining, family restaurants? Pan fried? Baked/roasted? Stewed? Oven-broiled? Grilled/barbecued? How often was the fish you ate: Fried/fast food? Casual dining, family restaurants? Pan fried? Oven-broiled? Baked? Grilled/barbecued? Raw? OR Medium OR OR PLEASE DO NOT WRITE IN THIS AREA / OF Medium well / OF / OF / OF Well done / OF / OF / OF Very well done / OF / OF [SERIAL] ALWAYS OR ALWAYS Don't know ALWAYS OR ALWAYS ALWAYS OR ALWAYS

11 Did you eat any pork chops or ham steaks? When did you eat foods that have been grilled (cooked over coals, open fire, or gas grill)? How would you describe your lifetime consumption of unpasteurized milk? (Mark one answer.) Never drank unpasteurized milk Drank it only as a child Drank it only as an adult How did you usually eat them? Baked Did you eat bacon or sausage? How did you usually eat them? Just until done Never All year round Mostly in the summer (June through September) How often did you eat grilled or barbecued meat (including beef, pork, chicken, or fish)? Less than once a month to times a month Once a week to times a week to times a week Almost every day How often did you eat meat which has been charred/blackened by grilling or barbecuing? Drank it as a child and as an adult Grilled Fried Broiled Well-done, crisp Charred/blackened Never Rarely Sometimes Often Don't know Don't know - -

12 Before one year ago, did you take any vitamins or minerals at least once a week for more than six months? - - Multiple Vitamins t counting multiple vitamins, did you take any of the following vitamins or minerals before one year ago? Vitamin A (not beta carotene) Beta Carotene Vitamin C Vitamin E Folic Acid Vitamin B Vitamin B Calcium (include Tums) Zinc Selenium Niacin Vitamin D Iron Magnesium - TIMES HOW OFTEN? - TIMES ONCE EVERY MORE THAN PLEASE DO NOT WRITE IN THIS AREA FOR HOW MANY YEARS? If you took a multiple vitamin, please name the specific brand and type: LESS THAN YR. - YRS. - YRS. - YRS. + YRS., Mayo Foundation for Medical Eduction and Research (MFMER). All rights reserved. USUAL DOSE?, IU or less, IU or more, IU or less, IU or more mg or less mg or more IU or less IU or more µg or less µg or more mg or less mg or more µg or less µg or more mg or less mg or more mg or less mg or more µg or less µg or more [SERIAL]