BRIEF FOOD QUESTIONNAIRE

Transcription

1 RESPONDENT ID NUMBER TODY'S DTE Jan Feb DY YER Mar pr May Jun Jul ug Sep Oct Nov Dec BRIEF FOOD QUESTIONNIRE 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 print your name in this box. pple juice Rice FEW YER - SEX Male Female If female, are you pregnant or breast feeding? PLESE DO NOT WRITE IN THIS RE No Yes Not female - - DY GE glasses WEIGHT pounds HEIGHT ft. in. This form is about your usual eating habits in the past year or so. This includes all meals or snacks, at home or in a restaurant or carry-out. There are two kinds of questions for each food. HOW OFTEN, on average, did you eat the food during the past year? *Please DO NOT SKIP any foods. Mark "Never" if you didn't eat it. HOW MUCH did you usually eat of the food? *Sometimes we ask how many you eat, such as egg, eggs, etc., ON THE DYS YOU ET IT. *Sometimes we ask "how much" as, B, C or D. LOOK T THE ENCLOSED PICTURES. For each food, pick the picture (bowls or plates) that looks the most like the serving size you usually eat. (If you don't have pictures: =/ cup, B=/ cup, C= cup, D= cups.) EXMPLE: 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). TYPE OF FOOD HOW OFTEN IN THE PST YER HOW MUCH ECH TIME PICTURES FOR -B-C-D Berkeley, C PH: -- Block -Brief BDDS Phone ()--

2 Eggs, including egg biscuits or Egg McMuffins (Not egg substitutes) Bacon or breakfast sausage, including sausage biscuit Cooked cereals like oatmeal, cream of wheat or grits Cold cereals like Corn Flakes, Cheerios, Special K, fiber cereals Bananas TYPE OF FOOD Oranges, tangerines, not including juice pplesauce, fruit cocktail, or any canned fruit ny other fruit, like grapes, melon, strawberries, peaches HOW OFTEN IN THE PST YER FEW YER - How often do you eat each of the following foods all year round? Which cereal do you eat most often? MRK ONLY ONE: Product, Just Right, Total Cheese, sliced cheese or cheese spread, including on sandwiches. Yogurt (not frozen yogurt) How often do you eat each of the following fruits? pples or pears - - DY HOW MUCH ECH TIME PICTURES FOR -B-C-D eggs pieces Which bowl Which bowl slices Bran Buds, Raisin Bran, Fruit-n-Fiber, other fiber cereals Other cold cereal, like Corn Flakes, Cheerios, Special K / / / Berkeley, C PH: -- PGE

3 TYPE OF FOOD HOW OFTEN IN THE PST YER FEW YER DY HOW MUCH ECH TIME PICTURES FOR -B-C-D How often do you eat each of the following vegetables, including fresh, frozen, canned or in stir fry, at home or in a restaurant? French fries, fried potatoes or hash browns White potatoes not fried, incl. boiled, baked, mashed & potato salad Sweet potatoes, yams, or sweet potato pie Rice, or dishes made with rice Baked beans, chili with beans, pintos, any other dried beans Refried beans Green beans or green peas Broccoli Carrots, or stews or mixed vegetables containing carrots Spinach, or greens like collards Cole slaw, cabbage Green salad Raw tomatoes, including in salad Catsup, salsa or chile peps TBSP. Salad dressing or mayonnaise (Not lowfat) TBSP. ny other vegetable, like corn, squash, okra, cooked green peps, cooked onions Vegetable soup, vegetable beef, Which chicken vegetable, or tomato soup bowl / / Berkeley, C PH: -- PGE

4 PLESE DO NOT WRITE IN THIS RE METS TYPE OF FOOD HOW OFTEN IN THE PST YER FEW YER DY HOW MUCH ECH TIME PICTURES FOR -B-C-D Do you ever eat chicken, meat or fish? Hamburgers, cheeseburgers, meat loaf, at home or in a restaurant Tacos, burritos, enchiladas, tamales Beef steaks, roasts, pot roast, or in frozen dinners or sandwiches Pork, including chops, roasts, or dinner ham When you eat beef or pork, do you Mixed dishes with meat or chicken, like stew, corned beef hash, chicken & dumplings, or in frozen meals Fried chicken, at home or in a restaurant Chicken or turkey not fried, such as baked, grilled, or on sandwiches When you eat chicken, do you meat / lb. / lb. / lb. / lb. Fried fish or fish sandwich, at home or in a restaurant ny other fish or shellfish not fried, including tuna Hot dogs, or sausage like Polish, Italian or Chorizo Boloney, sliced ham, turkey lunch meat, other lunch meat slices When you eat lunch meats, are they Yes No IF NO, SKIP TO NEXT PGE # medium pieces Usually low-fat Sometimes Rarely low-fat N/ void eating the fat Sometimes eat the fat Often eat the fat I don't eat meat void eating the skin Sometimes eat the skin Often eat the skin N/ Berkeley, C PH: -- PGE

5 PLESE DO NOT WRITE IN THIS RE Cheese dishes without tomato sauce, like macaroni and cheese Biscuits, muffins TYPE OF FOOD Pasta, breads, spreads, snacks Spaghetti, lasagna, or other pasta with tomato sauce Pizza, including carry-out Rolls, hamburger buns, English muffins, bagels White bread or toast, including French, Italian, or in sandwiches Dark bread like rye or whole wheat, including in sandwiches Tortillas Margarine on bread, potatoes or vegetables Butter on bread, potatoes or vegetables Peanuts or peanut butter Snacks like potato chips, corn chips, popcorn (Not pretzels) Doughnuts, cake, pastry, pie Cookies (Not lowfat) Ice cream, frozen yogurt, ice cream bars When you eat ice cream or frozen yogurt, is it Chocolate candy, candy bars HOW OFTEN IN THE PST YER FEW YER DY HOW MUCH ECH TIME PICTURES FOR -B-C-D slices slices / slices pats (Tsp.) pats (Tsp.) TBSP. pieces Usually low-fat Sometimes Rarely low-fat N/ bars - small medium large large Berkeley, C PH: -- PGE

6 TYPE OF BEVERGE Real orange or grapefruit juice, Welch's grape juice, Minutemaid juices, Juicy Juice Instant breakfast milkshakes like Carnation, diet shakes like Slimfast, or liquid supplements like Ensure Glasses of milk (any kind) Wine or wine coolers HOW OFTEN IN THE PST YER FEW YER How often do you drink the following beverages? Hawaiian Punch, Sunny Delight, Hi-C, Tang, or Ocean Spray juices Kool id, Capri Sun or Knudsen juices When you drink glasses of milk what kind do you usually drink? MRK ONLY ONE: - Whole milk Reduced fat % milk Low-fat % milk - - Non-fat milk Rice milk Soy milk DY HOW MUCH ECH TIME PICTURES FOR -B-C-D glasses each time glasses or cans glasses each time glasses each time glasses I don't drink milk or soy milk Cream, Half-and-Half or non-dairy Total TBSP. on creamer in coffee or tea those days - + Regular soft drinks, or bottled drinks bottles or like Snapple (Not diet drinks) cans - + Beer Liquor or mixed drinks bottles or cans - glasses - + drinks - + Berkeley, C PH: -- + PGE

7 During the past year, have you taken any vitamins or minerals regularly, at least once a month? No, not regularly Yes, fairly regularly (IF YES) WHT DID YOU TKE FIRLY REGULRLY? VITMIN TYPE Multiple Vitamins. Did you take Regular Once--Day, Centrum, or Thera type Stress-tabs or B-Complex type ntioxidant combination type Single Vitamins (not part of multiple vitamins) Vitamin (not beta-carotene) Beta-carotene Vitamin C Vitamin E Folic acid, folate Calcium or Tums, alone or combined with vit. D or magnesium Zinc Iron Selenium Vitamin D, alone or combined with calcium HOW OFTEN If you took vitamin C or vitamin E: milligrams of vitamin C did you usually take, on the days you took it? + don't know IUs of vitamin E did you usually take, on the days you took it? + don't know DIDN'T TKE FEW DYS How often do you use fat or oil in cooking? Less than once week few times week Once a day What kinds of fat or oil do you usually use in cooking? MRK ONLY ONE OR TWO Don't know, or Pam Stick margarine Soft tub margarine Butter Butter/margarine blend Low-fat margarine Corn oil, vegetable oil Olive oil or canola oil Lard, fatback, bacon fat Crisco Did you ever drink more beer, wine or liquor than you do now? Yes No Do you smoke cigarettes now? Yes No IF YES, On the average about how many cigarettes a day do you smoke now? or more FOR HOW MNY YERS? Twice a day + day What is your ethnic group? (MRK ONE OR MORE) Hispanic or Latino Black or frican merican merican Indian or laska Native White, not Hispanic sian Native Hawaiian or Other Pacific Islander - DYS - DYS DY LESS THN YR. YER YERS YERS YERS YERS Berkeley, C PH: -- Thank you very much for filling out this questionnaire. Please take a minute to go back and fill in anything you may have skipped. PLESE DO NOT WRITE IN THIS RE PGE

8 Berkeley, C PH: -- PLESE DO NOT WRITE IN THIS RE PGE Mark Reflex by Pearson NCS MM- Printed in U.S..