**[Nutrition Questionnaire About Eating Practices]{.underline}**

1.  **Breakfast.** How often do you eat breakfast, more than just a roll
    and a cup of coffee?

    1.  eat breakfast everyday

    2.  east breakfast most mornings

    3.  eat breakfast two to three times per week

> \(4\) seldom or never eat breakfast

2.  **Snacks.** How often do you eat snack foods between meals (chips,
    pastries, soft drinks, candy, ice cream, cookies)?

    1.  three or more times per day

    2.  once or twice per day

    3.  few times per week

    4.  seldom or never eat typical snacks

3.  **Fast Food.** How often do you eat fast food meals such as
    hamburgers, tacos, fried chicken, hot dogs, French fries,
    milkshakes, etc.?

    1.  four or more times per week

    2.  two to three times per week

    3.  two to four times per month

    4.  seldom or never

4.  **Fat intake.** Indicate the kinds of foods you usually eat.

> **High fat examples:** hamburgers, hot dogs, bologna, steaks, sour
> cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream,
> chocolate, fried foods and many fast foods.
>
> **Low fat examples:** lean meats, skinless poultry, fish, skim milk,
> low fat dairy products, fruit desserts, gelatin, vegetables, pasta,
> legumes (peas and beans)

(1) nearly always eat the high fat foods

(2) eat mostly the high fat foods, some low fat

(3) eat both about the same

(4) eat mostly low fat foods, some high fat

(5) eat only low fat foods

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5.  **Breads and grains:** Indicate the kinds of breads and grains you
    usually eat.

> **Refined grain examples:** white bread, rolls, regular pancakes and
> waffles, white rice, typical breakfast cereals, typical baked goods
>
> **Whole-grain examples:** whole-grain breads, brown rice, oatmeal,
> whole-grain or high fiber cereals

(1) nearly always eat refined grain products

(2) eat mostly refined grain products

(3) eat both about the same

(4) eat primarily whole-grain products

(5) eat only whole-grain products

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6.  **Protein foods.** Indicate the kinds of protein foods you usually
    eat.

> **Animal sources:** meats, poultry, fish, cheese, eggs
>
> **Vegetable sources:** legumes (peas, beans, lentils), tofu, soy
> meats, nut foods, veggie burger, vegetarian entrees

(1) nearly always eat animal proteins

(2) eat mostly animal proteins

(3) eat both about the same

(4) eat mostly vegetable proteins

(5) eat only vegetable proteins

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7.  **Dark leafy green vegetables.** How often do you eat dark leafy,
    green vegetables?

> **Examples:** spinach, kale, broccoli, turnip greens, and collard
> greens.

1.  five or more times per week

2.  two to four times per week

3.  once per week

4.  one to three times per month

5.  seldom or never

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8.  **Food groups.** How many servings do you eat of the following food
    groups each day?

**Servings Per Day**

**[0 2 4 6 8 10+]{.underline} [Serving Size]{.underline}**

**GRAINS**

1.(0)(2)(4)(6)(8)(10+) 1 slice bread, 1 oz. dry cereal, ½ cup cooked

cereal, rice, or pasta

**VEGETABLES**

2\. (0)(1)(2)(3)(4)(5+) 1 cup raw, ½ cup cooked,

> ¾ cup juice, 1 medium potato

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**FRUIT**

3\. (0)(1)(2)(3)(4)(5+) 1 medium apple, orange,

banana, ½ cup cooked,

¾ cup juice

**DAIRY**

4\. (0)(1)(2)(3)(4)(5+) 1 cup milk or yogurt,

1.5 oz. natural

cheese, 2 oz.

processed cheese

**PROTEIN FOODS**

5\. (0)(1)(2)(3)(4)(5+) 2 to 3 oz. cooked lean

meat, poultry, or fish,

1 large egg, 1 cup

> cooked beans, lentils,
>
> peas, 3 oz. tofu, 1 oz.
>
> nuts, 1 3 oz. vegetarian
>
> burger

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SWEETS & DESSERTS**

6\. (0)(1)(2)(3)(4)(5+) 12 oz. soft drink,

1 small candy bar,

2 tbs. sugar or jam,

2 small cookies,

½ cup ice cream,

1 slice pie or cake

**FAT**

7\. (0)(1)(2)(3)(4)(5+) 1 tbs. butter, oil, or

margarine, 2 tbs. salad

> salad dressing or mayonnaise

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9.  **Salt.** How often do you add salt to your food or eat salty foods
    (chips, pickles, soy sauce)?

    1.  seldom or never

    2.  some meals

    3.  most meals

    4.  nearly every meal

10. **Water.** How many 8 ounce glasses of water do you usually drink
    each day?

    1.  one or less

    2.  two

    3.  three

    4.  four

    5.  five

    6.  six

    7.  seven

    8.  eight or more

11. **Prior Weight.** Compared to your weight 10 years ago, how much do
    you weigh now?

    1.  10 pounds more

    2.  20+ pounds more

    3.  weigh about the same

    4.  weigh less now

12. **Calcium.** Do you take a calcium supplement regularly?

    1.  yes

    2.  no

13. **Dieting.** Do you diet often, at least 1-2 times a year?

    1.  yes

    2.  no

14. **Caffeine.** How many caffeinated drinks do you usually drink per
    day, such as coffee, tea, and cola? *One drink is the equivalent of
    a cup of coffee or tea, or a 12 ounce cola drink.*

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(1) no

(2) one per day

(3) two per day

(4) three per day

(5) four per day

(6) five per day

(7) six or more per day

> Source: [Personal Wellness Profile]{.underline}, Parklawn Federal
> Occupational Health Unit, Rockville, MD, 2000.