Nutrient Deficiency Risk Questionnaire

Many_Americans_dont_get_enough_potassium,_calcium,_and_vitamin_D_from_the_foods_they_eat._Additionally,_certain_groups_ of_people_may_not_be_getting_as_much_iron,_folate,_or_vitamin_B-12_as_they_need._To_help_determine_whether_you_are_getting_ enough_of_these_nutrients_from_your_diet,_answer_the_questions_below._Then_discuss_your_answers_with_your_family_doctor.

Your name:______________________________________________________________ Your doctors name:_______________________________________________________

Age and Lifestyle 1._ Are_you_a_woman_14_to_50_years_of_age?_ 2._ Are_you_50_years_of_age_or_older?_ 3._ Are_you_pregnant_or_trying_to_get_pregnant?_ 4._ Are_you_vegetarian_or_vegan?_ 5._ Do_you_take_nutritional_supplements?_ _

Yes_ __ No Yes___ __ No Yes_ __ No Yes_ __ No Yes_ __ No

If_yes,_what_kind?___________________________________________________________________________________________________

6._ _ hen_the_weather_is_nice,_how_often_do_you_spend_at_least_10_minutes_a_day_in_full_sun_without_sunscreen? W __ Daily 3-5 times a week 1-3 times a week Not on a regular basis Never General Nutrition 1. How_often_do_you_buy_food_from_the_outer_aisles_of_the_grocery_store?_ (i.e.,_fresh_or_frozen_fruits_and_vegetables,_fresh_meat_or_seafood,_dairy,_grains,_and_nuts_from_the_bulk_bins)__

All the time

Often

Sometimes

Not at all

2._ _ ow_often_do_you_buy_food_from_the_center_aisles_of_the_grocery_store?__ H (i.e.,_foods_that_come_in_cans,_bags,_or_boxes,_such_as_crackers,_canned_soups,_cereals,_and_frozen_dinners)__ _

Not at all Not at all

Sometimes Sometimes

Often Often

All the time

_

3._ _ ow_often_do_you_eat_out_at_restaurants_or_fast-food_restaurants?__ H

All the time

4._ _ hat_do_you_eat_when_you_snack?_____________________________________________________________________________________ W Fruits and Vegetables 1._ _ ow_often_do_you_eat_fresh_or_frozen_green_vegetables,_such_as_kale,_collard_greens,_chard,_or_spinach?__ H

All the time

Often

Sometimes

Not at all
_

2._ _ ow_often_do_you_eat_fresh_or_frozen_fruits_and_vegetables_from_at_least_3_different_color_groups__ H (e.g.,_red_berries,_purple_eggplant,_orange_sweet_potatoes,_and_green_broccoli)_all_in_one_day?__

All the time

Often

Sometimes

Not at all

3._ _ hat_are_your_favorite_fruits_and_vegetables?_____________________________________________________________________________ W Dairy, Seafood, and Meat 1._ _ ow_often_do_you_eat_low-fat_dairy_products_such_as_yogurt_or_cheese,_soy,_or_rice-milk_products?__ _ H

All the time All the time Not at all All the time Not at all Not at all

Often Often Sometimes Often Sometimes Sometimes

Sometimes Sometimes Often Sometimes Often Often

Not at all
_ _

2._ _ ow_often_do_you_eat_fish,_such_as_sardines,_salmon,_trout,_and_tilapia?__ H

Not at all All the time

_

3._ _ ow_often_do_you_eat_red_meat,_such_as_beef,_mutton,_lamb,_goat,_and_game_meats_(e.g.,_rabbit,_venison,_buffalo)?__ H 4._ _ ow_often_do_you_eat_other_meats,_such_as_chicken,_turkey,_pork,_and_game_birds_(e.g.,_pheasant,_quail)?__ H

Not at all
_

5._ _ ow_often_do_you_eat_processed_meats,_such_as_bacon,_sausage,_hot_dogs,_and_bologna?__ H

All the time

_ This content was developed with support from Nature Made.

6._ _ ow_often_do_you_eat_fried,_canned,_or_smoked_meats?__ H

All the time

Americans In Motion - Healthy Interventions