Part : Demographics a. Last Name: PLEASE DO NOT WRITE IN THIS AREA SERIAL # Mark Reflex forms by Pearson NCS MM- HC Printed in U.S.A.. To's Date:. Phone Number:. Age:. Sex:. Which of the following responses best describes your citrus fruit or juice consumption in the past year? Frequent or regular consumption Occasional In season ONLY Male Female years old Month Day Year DIRECTIONS Use a # pencil Make no stray marks Fill in the circles completely Please shade bubbles like this: and not like this: ID NUMBER OFFICE USE ONLY ) ( Questionnaire USE A NO. PENCIL ONLY Please print your Name, To's Date, Phone Number, Age, and Sex in the boxes provided. b. First Name: STUDY A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z STAGE
Part : Juice. During the last year, how often did you drink the following juices? Please fill in a bubble for EACH type of juice. Page cup/ - cup - - - + Orange Juice Grapefruit Juice Lemonade Limeade. If you drank any of the following juices in the last year, what was the size? Please fill in a bubble for each juice. Did Not Drink Small Medium ( oz) Large Orange Juice Grapefruit Juice Lemonade Limeade. If you drank any of the following juices in the last year, please indicate how it was usually prepared? Orange Juice Did Not Drink Fresh at Home Frozen Concentrate Ready Made in Glass Container Ready Made in Plastic Container Ready Made in Carton Container Ready Made in Cans As a Soda/ Hi-C Thirst Quencher As Part of Mixed Fruits Don't Grapefruit Juice Lemonade Limeade
Part : Fruits. During the last year, how often did you eat the following citrus fruits? Please fill in a bubble for EACH type of fruit. Oranges time/ - time - - - Page + Grapefruit Other Fruits. In season, how often do you eat the following citrus fruits? If none, leave box empty. ANGES GRAPEFRUIT OTHER CITRUS FRUITS. When you ate the following fruit, what was the serving size? Please fill in a bubble for each fruit. Oranges Grapefruit Other Fruits Did Not Eat / fruit / fruit fruit / fruits + fruits. When you ate the following fruit, was it usually: Please fill in a bubble for each fruit. Oranges Grapefruit Other Fruits Did Not Eat Fresh Canned
Part : Peel and Other Products peel/zest Marmalade SERIAL # pies/cakes PLEASE DO NOT MARK IN THIS AREA. During the last year, how often did you consume or add the following to a recipe? Please fill in a bubble for EACH type of citrus product. time/ - time - - - Page +. When you consumed or added the following to a recipe, what was the serving size? Please give a value for EACH type you used. CITRUS PEEL/ZEST MARMALADE CITRUS PIES/CAKES tablespoons Peel of medium fruit tablespoons None Small Medium Large. If you used or consumed citrus peel or zest, what was the citrus peel or zest used for? A) B) C). How many lemons or limes do you use: a. Do you have citrus trees in your backyard? Yes No b. If you have citrus trees in your backyard, what kind??? A) B) C)
SERIAL # Part : Addition PLEASE DO NOT MARK IN THIS AREA Page. How often do you add fresh lemon or lime to your food before eating? (Fish, soup, salad, dip, beans, sauce, etc...) Please fill in a bubble for both lemon and lime. Lemon Lime time/ - time - - - +. When you added fresh lemon/lime to your food, how much did you use? Please give a value for EACH type you used. Lemon Lime. How often do you add fresh lemon or lime to your tea, water, and other alcoholic or non-alcoholic beverages? Please fill in a bubble for both lemon and lime. Lemon Never added / / / / + time/ - time - from a glass - from a plastic - + Lime. When you added fresh lemon/lime to your beverages, how much did you use? Please give a value for EACH type you used. from a glass from a plastic Lemon Lime Never added / / / / +
Part : Food preparation. How often do you include fresh lemon as part of the recipe? Fish % % % % % Don't Page Meat Chicken. How much lemon do you use or squeeze serving? Fish Meat Chicken from a glass Never added / / / / / + Don't. How often do you include fresh lime as part of the recipe? Fish Meat Chicken % % % % % Don't from a plastic. How much lime do you use or squeeze serving? Fish Meat Chicken Never added / / / / / + Don't from a glass from a plastic
Thank You For Your Time
PLEASE DO NOT WRITE IN THIS AREA SERIAL # Interview Method: Admin. by: Office visit Phone Mail Other Tech Admin. by Self Guardian Other Init. OFFICE USE ONLY: Form Status: Collapsed: Y N Form Status: QC: Init. Init. QA: Tech. ID MO DAY YEAR Tech. ID MO DAY YEAR Peel Codes: A B C Tree Codes: A B C