Food Questionnaire

E
PL
This form asks about your usual food intake during ________________________________ .
M
Please use pencil.

Answer by filling in the correct oval.

SA

Yes No
TODAY'S DATE IDENTIFICATION
MO DAY YEAR NUMBER

Do not make any other

marks on the form. Please 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

use a separate piece of 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

paper to make comments. 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

SEX 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Male 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Female 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

8 8 8 8 8 8 8 8 8 8 8 8 8 8 8

MNA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

PLEASE DO NOT WRITE IN THIS AREA

 Part I: Usual Food Choices
These questions are about the types of foods you ate during ____________________________________.

1. Did you eat chicken or turkey? 5. Did you eat cold cereals?

Yes ➤ When you ate chicken or Yes ➤ When you ate cold cereal,
No turkey, how often did you eat No what type did you usually eat?
the skin? Mark one or two.
➤

➤
Almost always Highly fortified cereals (100%
Often of Daily Values) such as Total®,
Sometimes Smart Start® and Product 19®
Rarely High fiber or bran cereals
Never such as Raisin Bran®

E
and All Bran®
2. Did you eat beef, pork, ham or lamb? Sweetened cereals such as
Frosted Flakes® or Fruit Loops®
Yes ➤ When you ate beef, pork, ham All other cereals such as
No or lamb, how often did you eat Cheerios ®, Corn Flakes®

PL
the fat? and granola
➤

Almost always
Often 6. Did you put milk (all types), cream or
Sometimes creamer on cereal?
Rarely
Never Yes ➤ When you put milk, cream or
No creamer on cereal, what type
3. Did you eat hamburger or other did you usually use?

➤
M ground meat? Mark one or two.
Cream or half and half
Yes ➤ When you ate hamburger or Whole milk
No other ground meat, was it 2% milk
usually... Mark one or two. 1% milk or buttermilk
➤

Regular Nonfat or skim milk

SA

Lean Soy milk

Extra lean Non-dairy creamer
Ground chicken or turkey Don’t know
Don’t know

4. Did you drink orange, grapefruit or

other fruit juices?

Yes ➤ Were any of these vitamins or

No minerals added (specially
fortified) to the juices you
➤

drank? Mark all that apply.

Extra Vitamin C
Vitamin E
Calcium
None
Don’t know

2
 7. Did you put milk (all types), cream or 11. Did you eat cookies or cakes?
creamer in coffee or tea?
Yes ➤ When you ate cookies or
Yes ➤ When you put milk, cream or No cakes, how often were they
No creamer in coffee or tea, fig bars, angel food cakes, or

➤
what type did you usually other types of low or nonfat

➤
use? Mark one or two. cookies or cakes?
Cream or half and half Almost always
Whole milk Often
2% milk Sometimes
1% milk or buttermilk Rarely
Nonfat or skim milk Never
Soy milk
Non-dairy creamer
12. In your household, what kinds of fat were
Don’t know
usually used when cooking, for example to

E
flavor vegetables or fry meat?
8. Did you drink milk (all types)? Also include Mark up to four.
beverages made with milk, such as lattes,
cappuccinos, mochas or hot chocolate. Butter
Butter blended with oil or margarine

PL
Yes ➤ When you drank milk or Stick margarine
No beverages made with milk, Regular tub margarine
was it usually… Diet or light margarine (tub or liquid)
➤

Mark one or two. Olive oil

Whole milk Canola oil
2% milk Other oils such as corn, soybean, peanut
1% milk or buttermilk and safflower
Nonfat or skim milk Lard, bacon fat or meat drippings
M Soy milk Didn’t use fat or used non-stick spray
Don’t know (Pam®)

9. Did you use salad dressing? 13. What kinds of fat did you use at the table,
for example on breads, vegetables
Yes ➤ When you used salad
SA

or potatoes? Mark up to four.

No dressing, what type did you
usually use? Mark one or two. Butter
➤

Regular, including oil Butter blended with oil or margarine

and vinegar Stick margarine
Low or reduced fat Regular tub margarine
Fat free or nonfat Diet or light margarine (tub or liquid)
Olive oil
Sour cream
10. Did you use mayonnaise?
Didn’t use fat
Yes ➤ When you used mayonnaise,
No what type did you usually
use? Mark one or two.
➤

Regular
Low or reduced fat
Fat free or nonfat

PLEASE DO NOT WRITE IN THIS AREA

3
 Part II: Usual Food Use
These questions are about foods you ate during ______________________________________________.

14. Mark the column to show how often, on average, you ate the following foods.
Mark your usual serving size as small, medium or large.
• A small serving is about one-half (1/2 ) the medium serving size or less.
• A large serving is about one-and-a-half (11/2 ) times the medium serving size or more.

EXAMPLE: This person ate spaghetti with meat sauce every Saturday. They usually ate about 11/2 cups.
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

E
Spaghetti, lasagna, and other
11/2 cups
pasta with tomato with meat sauce

CEREALS, BREADS, SNACKS

PL
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Cold cereals 11/2 cups

Cooked cereals and grits 11/2 cups

M
Milk on cereals 3/ cup
4

Pancakes, French toast and waffles 2 pieces

Muffins, scones, croissants 1 medium

and biscuits
SA

White breads, including bagels, 2 slices or

rolls and English muffins 1 medium
2 slices or
Whole grain breads and rolls 1 medium
Plain tortillas as a side dish 3 small or
(include flour and corn) 1 large
2 slices or
Cornbread and corn muffins 1 medium
Butter or margarine on breads, 2 pats or 2
cereals, pancakes, etc. teaspoons
Jam, jelly, honey, syrup and sugar
2 Tbsp.
(including in coffee, tea and cereal)
Granola bars and cereal bars 1 bar
such as Nutri-Grain Bars®
Sports or meal replacement
bars such as Power Bars® and 1 bar
Clif Bars®

4
 HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
CEREALS, BREADS,
NEVER or
SNACKS (continued) less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Low or nonfat potato chips, tortilla 4 handfuls

chips, corn chips and pretzels or 1 med. bag
Regular potato chips, tortilla 4 handfuls
chips, corn chips and puffs or 1 med. bag
Plain popcorn (no butter) or lowfat 8 handfuls
microwave popcorn
Buttered or regular microwave 8 handfuls
popcorn
Low or nonfat crackers such as 12
saltines medium
Whole grain crackers such as 12

E
Triscuits ® and rye crispbread medium
Regular crackers such as Ritz® 12
and club crackers medium
2 Tbsp.
Peanut butter, peanuts and

PL
(spreads) or
other nuts and seeds 1/ cup (nuts)
2

MEAT, FISH, EGGS

HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L
M
Eggs (egg substitute, mark "NEVER") 2 eggs

3 strips or
Bacon and breakfast sausage
2 links
Low or reduced fat hot dogs 2 hot dogs or
and sausage 4 ounces
SA

Regular hot dogs and sausage 2 hot dogs or

such as bratwurst and chorizo 4 ounces
Lunch meats such as ham, turkey 2 slices
and lowfat bologna
All other lunch meat such as 2 slices
bologna, salami and Spam®
Canned tuna, tuna salad and 1 can tuna
or 2 cups
tuna casserole casserole
Beef, pork, ham and lamb 6 ounces

Ground meat, including 1 medium patty

hamburgers and meatloaf or 4 ounces
Liver, chicken liver and 6 ounces
organ meats
Fried chicken, including 2 large pieces
nuggets and tenders or 9 nuggets

PLEASE DO NOT WRITE IN THIS AREA

5
MEAT, FISH, EGGS (continued)
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Chicken and turkey (roasted, 2 large or

4 small
stewed, grilled or broiled) pieces
Fried fish, fish sandwich and fried 4 ounces or
shellfish (shrimp and oysters) 1 sandwich
Shellfish, not fried (shrimp, 6 ounces
lobster, crab and oysters) or 1 cup
White fish (broiled or baked) such 6 ounces
as sole, halibut, snapper and cod
Dark fish (broiled or baked)

E
such as salmon, mackerel 6 ounces
and bluefish

SPAGHETTI, MIXED DISHES, SOUPS

PL
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Stew, pot pie, curries and 11/2 cups

casseroles with meat or chicken

Chili with meat and beans 11/2 cups

M
Spaghetti, lasagna and other 11/2 cups
pasta with tomato and meat sauce
Spaghetti and other pasta with 11/2 cups
tomato sauce (no meat)
Pasta with oil, cheese, or cream
sauce, including macaroni and 11/2 cups
SA

cheese
Asian-style (stir-fried) noodles
and rice such as chow mein, 11/2 cups
fried rice and Pad Thai

Pizza 3 slices

Tofu, tempeh and products 4 ounces,

such as tofu hot dogs, soy 2 hot dogs
burgers and tofu cheese or 1 burger
Burritos, tacos, tostadas 2 medium
and quesadillas

Enchiladas and tamales 2 medium

Vegetable, minestrone and 11/2 cups

tomato soup
Cream soups such as chowders, 11/2 cups
potato and cheese

6
SPAGHETTI, MIXED DISHES, SOUPS (continued)
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Bean soups such as pea, 11/2 cups

lentil and black bean

Miso soup 11/2 cups

Ramen noodle soup 11/2 cups

Other soups such as 11/2 cups

chicken noodle

E
DAIRY PRODUCTS
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving

PL
month month month week week week week day day size S M L

Cottage cheese and 3/ cup

4
ricotta cheese
Low or reduced fat cheese, 2 slices or
including cheese used 1/ cup
2
in cooking shredded

2 slices, 1/2
All other cheese (American,
cup shredded
cheddar or cream), including
M or 2 Tbsp.
cheese used in cooking
cream

Yogurt, all types except frozen 6 ounces

SA

VEGETABLES and GRAINS

HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L
Mark all vegetables you ate, including in salads, mixed dishes, sandwiches and stir-fries.

Green salad (lettuce or spinach) 2 cups

Salad dressing (all types) 1/ cup

4

1 medium
Fresh tomatoes
or 4 slices

Carrots 3/ cup
4

Green peppers and green chilies 1/ cup

2

Red peppers and red chilies 1/ cup

2

7
 HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
VEGETABLES and
NEVER or
GRAINS (continued) less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L
Mark all vegetables you ate, including in salads, mixed dishes, sandwiches and stir-fries.

Broccoli 3 / cup
4

Cauliflower, cabbage and 3 / cup

4
Brussels sprouts

Green or string beans 3 / cup

4

Green peas 3 / cup

4

Corn and hominy 3 / cup

E
4

Summer squash and zucchini 3 / cup

4

Winter squash such as acorn, 3 / cup

4
butternut and pumpkin

PL
Yams and sweet potatoes 1 medium

Cooked greens such as spinach, 3 / cup

4
mustard greens and collards

Onions and leeks 1/ cup

2

Fresh garlic, including in cooking 1 clove

M 1/ medium
2
Avocado and guacamole
or 1/2 cup
French fries, fried potatoes 1 cup
and hash browns
Potatoes (boiled, baked or 1 medium
mashed) or 1 cup
SA

Refried beans 3 / cup

4

All other beans (baked, lima 3 / cup

4
or chili without meat)

Coleslaw 3 / cup
4

Potato, macaroni and pasta salads 3 / cup

4
made with mayonnaise or oil
Brown rice, whole wheat pasta and 1 cup
other whole grains (as a side dish)
White rice, noodles and other 1 cup
grains (as a side dish)
Butter, margarine, sour cream
2 pats or 2
and other fat added to
teaspoons
vegetables, potatoes and rice

PLEASE DO NOT WRITE IN THIS AREA

8
SAUCES and CONDIMENTS
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Cheese sauce and cream sauce 1/ cup

2

Meat gravies 1/ cup

2

Ketchup 1/ cup
4

Salsa (as dip or on foods) 1/ cup

2

Mayonnaise and 2 Tbsp.

E
mayonnaise-type spreads

FRUITS
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?

PL
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Apples, applesauce 1 medium

and pears or 1/2 cup

Bananas 1 medium

1 medium
Peaches, nectarines and plums
M or 1/2 cup
2 medium
Apricots (fresh, canned or dried) or 4 halves
Dried fruit (other than apricots) 1/ cup
2
such as raisins and prunes
Oranges, grapefruit and
SA

1 orange or
tangerines (not juice) 1/grapefruit
2

Berries such as strawberries 3/ cup

4
and blueberries
Cantaloupe, orange melon 1/ melon or
4
1/ mango
and mango (in season) 2

Watermelon and red melon 1 large slice

Any other fruit such as grapes, fruit 3 /4 cup

cocktail, pineapple and cherries

9
SWEETS
HOW OFTEN DID YOU EAT THESE FOODS? ➤ AMOUNT?
NEVER or
less than 1 2-3 1 2 3-4 5-6 1 2+ Medium
once per per per per per per per per per serving
month month month week week week week day day size S M L

Low or nonfat frozen desserts

such as lowfat ice cream, frozen 2 scoops
yogurt and sherbet
2 scoops or
Ice cream and milkshakes 1 shake

Pudding, custard and flan 1 cup

1 medium
Doughnuts, pies and pastries piece or
slice

E
3 med.
Cookies and cakes cookies or
1 piece of
cake

Chocolate, candy bars 1 regular bar

or

PL
and toffee 4 pieces

Other candy such as

6 pieces or
Lifesavers®, licorice and
25 jellybeans
jelly beans

PLEASE ANSWER THESE THREE IMPORTANT QUESTIONS!

M NEVER or
less than 1-2 3-4 5-6 1 2 3 4 5+
once per per per per per per per per per
week week week week day day day day day
Note that the frequency headings are different.
How often did you eat foods that were
cooked in fat (pan-fried, sautéed, or
SA

deep-fried)? Count all fat such as

margarine, butter, oil or lard.
How often did you eat a serving
of vegetables? Do not count
potatoes, salad or beans.
How often did you eat a serving
of fruit? Do not count juices.

PLEASE DO NOT WRITE IN THIS AREA

10
BEVERAGES and ALCOHOL
HOW OFTEN DID YOU DRINK THESE BEVERAGES? ➤ AMOUNT?
NEVER or
less than 1-3 1 2-4 5-6 1 2-3 4-5 6+ Medium
once per per per per per per per per per serving
month month week week week day day day day size S M L
Note that the frequency headings are different.
Milk (all types) as a beverage 1 cup

Latte, cappuccino, mocha 1 cup

or hot chocolate

Coffee (not lattes or mochas) 1 cup

Tea, unsweetened or diet 1 cup

E
Tea, presweetened, bottled 1 cup
or instant
Milk, cream or creamer 1 Tbsp.
added to tea and coffee
Tomato juice, V-8® and other

PL
1 cup
vegetable juices

Orange juice and grapefruit juice 1 cup

Other 100% fruit juice such as 1 cup

apple, grape and cranberry
Fruit drinks fortified with Vitamin C
such as Hi-C®, and Kool-Aid® 1 cup

Meal replacement drinks and

M
shakes such as Slim-Fast® 1 cup
and Ensure®
Diet soft drinks 12 ounces
(include energy drinks) or 1 can
Regular soft drinks 12 ounces
(include energy drinks) or 1 can
SA

Water (tap, bottled or sparkling) 1 cup

12 ounce
Beer (all types) can or bottle
1 medium
Red wine glass (6 oz)
1 medium
White or rosé wine glass (6 oz)
1 shot
Liquor and mixed drinks (11/2 oz) or
1 mixed drink

THANK YOU!
Please take a moment to fill in any questions you may have skipped.

11
 E
PL
M
SA

PLEASE DO NOT WRITE IN THIS AREA

12 RD27063-PFI-54321