Food Frequency Questionnaire

Transcription

1 Arizona Arizona Cruciferous Tea Questionnaire Vegetable Food Frequency Questionnaire DIRECTION Use a #2 pencil. Keep marks within the circles. Thoroughly erase as needed. Correct Numbers and etters 2 3 A B C UE A NO. 2 PENCI ONY Demographic Information Please print the date, your age and your gender in the spaces provided below: OFFICE UE ONY ID NUBER: TO DATE: CINIC VIIT NUBER: AGE: years old ale Female How would you describe your appetite over the past few months or the time period you have been asked to review? Normal/usual Increased Decreased TUDY NUBER: Interview method: Clinic visit Telephone ail On line (Web-based) PEAE DO NOT WRITE IN THI AREA ERIA #

2 FOOD INTAKE The following two sections refer to COOKED vegetables ONY. A. How often did you eat the following COOKED cruciferous vegetables? Please also mark your usual portion ( = small, = medium, = large). < ERVING/ ONTH to 3 ERVING/ ONTH ERVING/ ERVING/ ERVING/ - 2 ERVING/ ERVING/ ERVING IZE Bok or Pak choy Broccoli spears Broccoli florets Broccoflower Broccolini Brussels sprouts Cabbage (green) Cabbage (red / purple) Cauliflower Chinese cabbage / Napa Collard greens Daikon root Garden cress / water cress Kale Kohlrabi ustard greens Rutabaga auerkraut Turnip Turnip greens On AVERAGE, how often do you eat the above COOKED cruciferous vegetables? 2

3 B. When cooking the above listed vegetables, what method of cooking did you usually (or most often) use? elect one method for each vegetable eaten. If a cooked form of the vegetable is never consumed, select Not Applicable. Not Applicable BAKE BOI BROI DEEP FAT FRY ICROWAVE TEA TEW TIR-FRY Bok or Pak choy Broccoli spears Broccoli florets Broccoflower Broccolini Brussels sprouts Cabbage (green) Cabbage (red / purple) Cauliflower Chinese cabbage / Napa Collard greens Daikon root Garden cress or water cress Kale Kohlrabi ustard greens Rutabaga Turnip Turnip greens Do you generally consume the liquid left from cooking these vegetables or use them to make soup? Yes No CONTINUE ON THE NEXT PAGE PEAE DO NOT WRITE IN THI AREA 3 ERIA #

4 The following section refers to RAW vegetables ONY. C. How often did you eat the following RAW (Uncooked) cruciferous vegetables? Please also mark your usual portion ( = small, = medium, = large). < ERVING/ ONTH to 3 ERVING/ ONTH ERVING/ ERVING/ ERVING/ - 2 ERVING/ ERVING/ ERVING IZE Arugula Bok or Pak choy Broccoli pears Broccoli Florets Broccoflower Broccolini Broccoli sprouts Brussels sprouts Cabbage (green) Cabbage (red / purple) Cauliflower 4

5 RAW vegetables ONY (Continued) < ERVING/ ONTH to 3 ERVING/ ONTH ERVING/ ERVING/ ERVING/ - 2 ERVING/ ERVING/ ERVING IZE Chinese cabbage/napa Coleslaw Daikon root Garden cress / water cress Kale Kohlrabi ustard greens Radicchio Radish On AVERAGE, how often do you eat the above RAW cruciferous vegetables? CONTINUE ON THE NEXT PAGE 5

6 D. On average, how often did you eat the following mixed dishes with cruciferous vegetables? Please also mark your usual portion ( = small, = medium, = large). < ERVING/ ONTH to 3 ERVING/ ONTH ERVING/ ERVING/ ERVING/ - 2 ERVING/ ERVING/ ERVING IZE Eggroll or spring roll Vegetable soup or stews with cruciferous vegetables eat/fish/ shell-fish with broccoli eat/fish/ shell-fish with other cruciferous vegetables Vegetarian Chinese dishes tuffed cabbage On AVERAGE, how often do you eat the above mixed dishes? Juice made with cruciferous vegetables: (ist vegetables used from pages 4 & 5 only) CONTINUE ON THE NEXT PAGE /2 PEAE DO NOT WRITE IN THI AREA 6 ERIA #

7 E. The following questions relate to the use of certain condiments or seasonings. On average, how often did you use the following to season food? Please also mark your usual portion = small (/2 tsp. to tsp.), = medium ( /2tsp. to tbsp.), = large (more than tbsp.) < ERVING/ ONTH to 3 ERVING/ ONTH ERVING/ ERVING/ ERVING/ - 2 ERVING/ ERVING/ ERVING IZE Horseradish Chinese mustard Brown mustard Yellow mustard ustard seed / powder Wasabi On Average, how often did you use the above condiments to season food? Thank You! Opcan inight forms by Pearson NC HC99 Printed in U..A. Developed by the Arizona Diet and Behavioral Assessment Center, Tucson, Arizona, UA Azdiet-behavior.azcc.arizona.edu 7

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