Food Frequency Questionnaire

Please provide the following information:

Do you have any particular concerns/questions regarding your food choices, eating habits and/or overall nutritional status.

The next section asks about your usual eating habits. For each question, select the response which best describes your usual behavior over the past year.

How many days each week do you eat breakfast?

None
1-2 days
3-5 days
6-7 days

What is your usual pattern for the evening meal?

This is my biggest meal
Medium size meal
Light meal
Seldom eat in the evening

Do the type of meals you usually eat include the following?

Red meats
Fish or chicken, but no red meats
Vegetarian meals with dairy or eggs
Vegan - no animal foods

How much water do you drink each day?

rarely
1-2 cups
3-5 cups
>5 cups

When salting your food, do you usually salt it?

Freely
Moderately
Sparingly
Never

Do you use non fat or low fat products?

Never
Rarely
Sometimes
Regularly

What kind of spread do you use most often?

Butter
Stick margarine
Soft tub margarine
none of these

What other kinds of fat do you use most often?

Shortenings, lard and/or animal fat
Vegetable oils
Use all of the above about the same
None of these

Does your work or daily activity primarily involve the following?

Sitting/driving
Standing
Walking or other active exercise
Heavy labor (eg. heavy lifting, etc)

Outside of your normal work or daily responsibilities, how often do you engage in exercise of 20 minutes or more which markedly increase your breathing (such as vigorous walking, cycling, running, swimming)?

Seldom or never
Less than once a week
1-2 times per week
3-5 times per week
6 or more times per week

Do you currently take a multi-vitamin?

Never
Rarely
Sometimes
Regularly

Do you take any other vitamin or mineral supplement?

Antioxidants
Calcium
Iron
Other

Do you take any nutritional supplements?

Never
Rarely
Sometimes
Regularly

The next section asks about your eating patterns during the past year. For each food, indicate your usual intake of that food per day, week, or month. For example: Eggs. If you eat 2 eggs every day, enter 2 under daily. If you average 2 eggs a week over the year, enter 2 under weekly. If you do not eat the food or if you have it rarely, then do not mark a frequency or interval. This questionnaire will take about 20 minutes to complete. The accuracy of your nutrition report depends on the accuracy of your answers.