0
1
2
3
4
5
1. Fruit juice, like orange, apple, grape , fresh, frozen or
canned. (Not sodas or other drinks)
0
1
2
3
4
5
2. How often do you eat
any fruit, fresh or canned (not counting juice)?
0
1
2
3
4
5
3. Vegetable juice, like tomato juice, V-8, carrot
0
1
2
3
4
5
4. Green salad
0
1
2
3
4
5
5. Potatoes, any kind, including baked, mashed or
french fried
0
1
2
3
4
5
6. Vegetable
soup or stew with vegetables
0
1
2
3
4
5
7. Any other
vegetables, including string beans, peas, corn, broccoli or any other kind
0
1
2
3
4
5
8. Fiber cereals
like Raisin Bran, Shredded Wheat or Fruit-n-Fiber
0
1
2
3
4
5
9. Beans such as
baked beans, pinto, kidney, or lentils (not green beans)
0
1
2
3
4
5
10.
Dark bread such as whole wheat or rye
Fat
Screener1
Think about your eating habits over the past year or so.
About how often do you eat each of the following foods?
Remember breakfast, lunch, dinner, snacks and eating out.
Next to each item, write the number that best represents the frequency of
intake of the following foods.
0 = 1/MONTHor less
1 = 2-3 times a MONTH
2 = 1-2 times a WEEK
4 = 5+ times a WEEK
0
1
2
3
4
1. Hamburgers, ground
beef, meat burritos, tacos
0
1
2
3
4
2. Beef or pork, such
as steaks, roasts, ribs, or in sandwiches
0
1
2
3
4
3. Fried chicken
0
1
2
3
4
4. Hot dogs, or Polish
or Italian sausage
0
1
2
3
4
5. Cold cuts, lunch
meats, ham (not low-fat)
0
1
2
3
4
6. Bacon or breakfast
sausage
0
1
2
3
4
7. Salad dressings (not
low-fat)
0
1
2
3
4
8. Margarine, butter or
mayo on bread or potatoes
0
1
2
3
4
9. Margarine, butter or
oil in cooking
0
1
2
3
4
10. Eggs (not Egg
Beaters or just egg whites)
0
1
2
3
4
11. Pizza
0
1
2
3
4
12. Cheese, cheese
spread (not low-fat)
0
1
2
3
4
13. Whole milk
0
1
2
3
4
14. French fries, fried
potatoes
0
1
2
3
4
15. Corn chips, potato
chips, popcorn, crackers
0
1
2
3
4
16. Doughnuts,
pastries, cake, cookies (not low-fat)
0
1
2
3
4
17. Ice cream (not
sherbet or non-fat)
Physical
Activity Questionnaire2
Which
of the following activities have you performed regularly?
Please check yes for each activity you have performed and no
if you have not performed the activity in the last
3 months If you have
performed an activity, please record how many hours per week you spent on the
activity during the last 3 months
Please also record how many hours you spent on the activity in the last
7 days
Sedentary
Activity Questionnaire2
Which
of the following activities have you performed regularly? Please
check yes for each activity you have performed and no if you have
not performed the activity in the last
3 months If you have
performed an activity, please record how many hours per week you spent on the
activity during the last 3 months
Please also record how many hours you spent on the activity in the last
7 days