NICOLA NUTRITION Self-Completion Questionnire Prticipnt Unique Reference (to be completed by nurse) Dte of completion (to be completed by nurse) D D M M Y Y Y Y
Food Frequency Questionnire The next set of questions sks bout your diet over the lst yer. For ech food there is n mount shown, either medium serving or common household unit such s slice or tespoon. Plese put tick in the box to indicte how often, on verge, you hve eten the specified mount of ech food during the pst yer. Exmple: For white bred the mount is one slice, so if you te or slices, you should put tick in the column heded -. FOODS AND AMOUNTS BREAD AND SAVOURY BISCUITS (one slice or biscuit) White bred nd rolls thn once - - - - - +
Exmple: For chips, the mount is medium serving, so if you hd helping of chips twice you should put tick in the column heded -. FOODS AND AMOUNTS POTATOES, RICE AND PASTA (medium serving) Chips thn once - - - - - + Exmple: For sesonl fruits such s strwberries nd rspberries you should estimte your verge use when the fruits re in seson, so if you te strwberries or rspberries bout once when they were in seson you should put tick in the column heded once. FOODS AND AMOUNTS Fruit ( fruit or medium serving) Strwberries, rspberries, Kiwi fruit thn once - - - - - +
FOODS & AMOUNT MEAT & FISH (medium serving) Beef; rost, stek, mince, stew or csserole thn once - - - - - + Beef burgers Pork; rost, chops, stew or slices Lmb; rost chops or stew Chicken or other poultry e.g. turkey Bcon Hm Corned beef, Spm, luncheon mets Susges Svoury pies e.g. met pie, pork pie, psties, stek & kidney pie, susge rolls Liver, liver pte, liver susge Fried fish in btter (fish & chips) Fish fingers, fish ckes
FOODS & AMOUNT MEAT & FISH (medium serving) Other white fish, fresh or frozen e.g. cod, hddock, plice, sole, hlibut Oily fish, fresh or frozen e.g. mckerel, kips, tun, slmon, srdines, herring Shellfish e.g. crb, prwns, mussels Fish roe, trmslt thn once - - - - - + BREAD & SAVOURY BISCUITS (one slice or biscuit) White bred nd rolls Brown bred nd rolls Wholemel bred nd rolls Crem crckers, cheese biscuits Crispbred e.g. Ryvit CEREALS (one bowl) Porridge, Redy Brek Brekfst cerel e.g. corn flkes muesli etc.
FOODS & AMOUNTS POTATOES, RICE AND PASTA (medium serving) thn once - - - - - + POTATOES, RICE AND PASTA (medium serving) Boiled, mshed, instnt or jcket pottoes Chips Rost pottoes Potto sld White rice Brown rice White or green pst e.g. spghetti, mcroni, noodles Wholemel pst Lsgne, moussk Pizz DAIRY PRODUCTS AND FATS Single or sour crem (tblespoon) Double or clotted crem (tblespoon) Low ft yoghurt, fromge fris (g crton)
FOODS & AMOUNTS DAIRY PRODUCTS AND FATS Full ft or Greek yoghurt (g crton) Diry desserts (g crton) Cheese e.g. cheddr, brie, edm (medium serving) Cottge cheese, low ft soft cheese (medium serving) Eggs s boiled, fried, scrmbled etc. (one) Quiche (medium serving) Low Clorie, low ft sld crem (tblespoon) Sld crem, myonnise (tblespoon) Other sld dressing (tblespoon) French dressing (tblespoon) thn once - - - - - + THE FOLLOWING ON BREAD OR VEGETABLES Butter (tespoon) Block mrgrine e.g. Stork, Kron (tespoon) Polyunsturted mrgrine (tub) e.g. Flor, sunflower (tespoon)
FOODS & AMOUNT DAIRY PRODUCTS AND FATS Other soft mrgrine, diry spreds (tub), e.g. Blue Bnd, Clover (tespoon) Low ft spred (tub) e.g. Outline, Gold (tespoon) Very low ft spred (tub) (tespoon) thn once - - - - - + SWEETS OR SNACKS Sweet biscuits, chocolte e.g. digestive (one) Sweet biscuits, plin e.g. Nice, ginger (one) Ckes e.g. fruit, sponge (home bked) Ckes e.g. fruit, sponge (redymde) Buns, pstries e.g. scones, flp jcks (home bked) Buns, pstries e.g. croissnts, doughnuts (redy-mde) Fruit pies, trts, crumbles (home bked) Fruit pies, trts, crumbles (redymde) Sponge puddings (home bked) Sponge puddings (redy-mde)
FOODS & AMOUNT DAIRY PRODUCTS AND FATS Milk puddings, e.g. rice, custrds, trifle thn once - - - - - + Ice crem, choc ices Chocoltes, single or squres Chocolte snck brs e.g. Mrs, Crunchie Sweets, toffees, mints Sugr dded to te, coffee, cerel (tespoon) Crisps or other pcket sncks e.g. Wotsits Penuts or other nuts SOUPS, SAUCES AND SPREADS Vegetble soups (bowl) Met soups (bowl) Suces e.g. white, cheese, grvy (tblespoon) Tomto ketchup (tblespoon) Pickles, chutney (tblespoon) 9
FOODS & AMOUNTS SOUPS SAUCES AND SPREADS (medium serving) Mrmite, Bovril (tespoon) Jm, mrmlde, honey (tespoon) thn once - - - - - + Penut butter DRINKS Te (cup) Coffee - instnt or ground (cup) Coffee - decffeinted (cup) Coffee whitener e.g. coffee-mte (tespoon) Coco, hot chocolte (cup) Horlicks, Ovltine (cup) Wine (glss) Beer, lger or cider (hlf pint) Port, sherry, vermouth, liqueurs (glss) Spirits e.g. gin, brndy, whisky, vodk (single)
FOODS & AMOUNTS DRINKS Low clorie or diet fizzy soft drinks (glss) Fizzy soft drinks e.g. Coc Col, lemonde (glss) Pure fruit juice (%) e.g. ornge, pple juice (glss) Fruit sqush or cordil (glss) thn once - - - - - + FRUIT - for sesonl fruits mrked *, plese estimte your verge use when the fruit is in seson Apples ( fruit) Pers ( fruit) Ornges, Stsum s, mndrins ( fruit) Grpefruit ( fruit) Bnns ( fruit) Grpes (medium serving) Melon ( slice) *Peches, plums, pricots ( fruit) *Strwberries, rspberries, kiwi fruit (medium serving)
FOODS & AMOUNTS FRUIT Tinned fruit (medium serving) Dried fruit e.g. risins, prunes (medium serving) thn once - - - - - + VEGETABLES - Fresh, frozen or tinned (medium serving) Crrots Spinch Broccoli, spring greens, kle Brussel sprouts Cbbge Pes Green ben, brod bens, runner bens Mrrow, courgettes Culiflower Prsnips, turnips, swedes Leeks
FOODS & AMOUNTS VEGETABLES - Fresh, frozen or tinned (medium serving) thn once - - - - - + Onions Grlic Mushrooms Sweet peps Bensprouts Green sld, lettuce, cucumber, celery Wtercress Tomtoes Sweetcorn Beetroot Coleslw Avocdo Bked Bens Dried lentils, bens, pes Tofu, soy met, TVP, veggieburger
Are there ny OTHER foods which you et more thn once? Yes No If YES, plese list below: FOOD Usul serving size e.g. smll, medium, lrge o tespoon Number of time eten ech
Wht type of milk do you most often use? Select ONE Full crem Skimmed Semiskimmed Dried Milk Soy Chnnel Islnds None OTHER (plese specify): How much milk do you drink ech, including milk with te, coffee, cerels etc.? Select ONE None Qurter of pint Hlf pint Three qurters of pint One Pint More thn pint Do you usully et brekfst cerel (excluding porridge & Redy Brek)? Yes No
If YES, which brnd nd type of brekfst cerel, including muesli, do you usully et? List the one or two types most often used Brnd e.g. Kellogg s Type e.g. cornflkes Wht kind of ft do you most often use for frying, rosting, grilling etc.? Select ONE Butter Mrgrine Vegetble oil Solid vegetble ft Lrd/dripping None If you used vegetble oil, plese give the nme or type e.g. corn, sunflower:
Wht kind of ft do you most often use for bking ckes etc.? Select ONE Butter Mrgrine Vegetble oil Solid vegetble ft Lrd/dripping None If you use mrgrine, plese give the nme or type e.g. Flor, Stork: How often do you et food tht ws fried t home? Dily - - Less thn once How often do you et fried food wy from home? Dily - - Less thn once
Wht do you usully do with the visible ft on your met? Et Et Et Did most some s little not et of the of the s met ft ft possible How often do you et grilled or rost met? Times How well-cooked do you usully hve grilled or rost met? Well done/ drk brown Medium Lightly cooked rre Do not et met How often do you dd slt to food while cooking? Alwys Usully Some Rrely
Do you regulrly use slt substitute? Yes No If YES, which brnd? 9
During the course of lst yer, on verge, how mny do you et the following food? Food Type Times Portion size Vegetbles (not including pottoes) Slds Fruit nd fruit products (not including fruit juice) Fish nd fish products Medium serving Medium serving Medium serving or one fruit Medium serving Met, met products nd met dishes (including bcon, hm nd chicken) Medium serving Hve you tken ny vitmins, minerls, fish oils, fibre or other food supplements during the pst yer? Yes No Some Don t know If YES or SOMETIMES, plese complete the tble overlef.
If you hve tken more thn types of supplement plese put the most frequently consumed brnds first. Exmple: Most supplements mention DOSE/STRENGTH vlue (e.g. mg); plese write this informtion in the tble i.e. mg If you tke one tblet of vitmin C two, plese write in the mount column nd tick the once box. Supplements Averge frequency for the pst yer. Tick ONE box line to show how often on verge you tke the mount consumed s mentioned in mount column. Brnd nme Dose Amount (wht is (How mny the tblets, strength cpsules or of ech tespoons tblet or do you tke cpsule s in one ) lbel?) Less thn once - Per - Per - Per
Do you void specific foods becuse of llergy or other helth problems? Yes No If YES, which food(s) do you void? (PLEASE LIST) Are you following specil diet? Yes No If YES: wht type of diet re you on? (Tick ny tht pply) Dibetic Weight Weight Low Cholesterol Other Other Diet Reduction Gin Ft Diet Medicl Diet Diet Diet Diet Diet
Ws this diet recommended or prescribed to you by doctor, nurse or dieticin or other medicl prctitioner? Yes No Do you find it difficult to follow this specil diet? Yes No If YES, cn you tell us why you find it difficult? Do you describe yourself s vegetrin or vegn? Vegetrin Vegn Neither
Who does the min food shopping in your household? List ll tht pply. Who does ll the cooking in your household? List ll tht pply.
How mny mels do you usully et ech? How mny of these mels re hot mels? How mny sncks do you usully et? Dte of completion D D M M Y Y Y Y Thnk you very much for tking the time to nswer our questions