This form asks about your usual food intake during ________________________________ . Please use pencil. Do not make any other marks on the form. Please use a separate piece of paper to make comments. 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 0 1 MO DAY YEAR TODAY'S DATE IDENTIFICATION NUMBER Answer by filling in the correct oval. Yes No Food Questionnaire Male Female SEX PLEASE DO NOT WRITE IN THIS AREA MNA SAMPLE
Transcript
This form asks about your usual food intake during ________________________________ .
Please use pencil.
Do not make any othermarks on the form. Pleaseuse a separate piece ofpaper to make comments.
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
MO DAY YEARTODAY'S DATE IDENTIFICATION
NUMBER
Answer by filling in the correct oval.
Yes No
Food Questionnaire
MaleFemale
SEX
PLEASE DO NOT WRITE IN THIS AREA
MNA
SAMPLE
2
YesNo
When you ate chicken orturkey, how often did you eatthe skin?
1. Did you eat chicken or turkey?
➤
➤
Almost alwaysOftenSometimesRarelyNever
Part I: Usual Food Choices
These questions are about the types of foods you ate during ____________________________________.
YesNo
2. Did you eat beef, pork, ham or lamb?
➤
➤
When you ate beef, pork, hamor lamb, how often did you eatthe fat?
Almost alwaysOftenSometimesRarelyNever
YesNo
When you ate hamburger orother ground meat, was itusually... Mark one or two.
3. Did you eat hamburger or otherground meat?
➤
➤
RegularLeanExtra leanGround chicken or turkeyDon’t know
YesNo
Were any of these vitamins orminerals added (speciallyfortified) to the juices youdrank? Mark all that apply.
4. Did you drink orange, grapefruit orother fruit juices?
➤
➤
Extra Vitamin CVitamin ECalciumNoneDon’t know
YesNo
6. Did you put milk (all types), cream orcreamer on cereal?
➤
➤
When you put milk, cream orcreamer on cereal, what typedid you usually use? Mark one or two.
Cream or half and halfWhole milk2% milk1% milk or buttermilkNonfat or skim milkSoy milkNon-dairy creamerDon’t know
YesNo
When you ate cold cereal,what type did you usually eat?Mark one or two.
5. Did you eat cold cereals?
➤
➤
Highly fortified cereals (100% of Daily Values) such as Total®,Smart Start® and Product 19®
High fiber or bran cereals ®
and All Bran®
® ®
All other cereals such as
such as Raisin Bran
Cheerios , Corn Flakesand granola
Sweetened cereals such as®FlakesFrosted ®or Fruit Loops
SAMPLE
Butter
Olive oilCanola oilOther oils such as corn, soybean, peanut
Lard, bacon fat or meat drippingsDidn’t use fat or used non-stick spray
®
YesNo
When you drank milk orbeverages made with milk,was it usually… Mark one or two.
8. Did you drink milk (all types)? Also includebeverages made with milk, such as lattes,cappuccinos, mochas or hot chocolate.
➤
➤
Whole milk2% milk1% milk or buttermilkNonfat or skim milkSoy milkDon’t know
YesNo
When you used mayonnaise,what type did you usuallyuse? Mark one or two.
10. Did you use mayonnaise?
➤
➤
RegularLow or reduced fatFat free or nonfat
YesNo
When you ate cookies orcakes, how often were they
11. Did you eat cookies or cakes?
➤
➤
OftenSometimesRarelyNever
YesNo
When you used saladdressing, what type did youusually use? Mark one or two.
9. Did you use salad dressing?
➤
➤
Regular, including oiland vinegarLow or reduced fatFat free or nonfat
Butter
Olive oil
Didn’t use fat
13. What kinds of fat did you use at the table,for example on breads, vegetables or potatoes? Mark up to four.
12. In your household, what kinds of fat wereusually used when cooking, for example toflavor vegetables or fry meat? Mark up to four.
YesNo
7. Did you put milk (all types), cream orcreamer in coffee or tea?
➤
➤
When you put milk, cream or creamer in coffee or tea,what type did you usuallyuse? Mark one or two.
Cream or half and halfWhole milk2% milk1% milk or buttermilkNonfat or skim milkSoy milkNon-dairy creamerDon’t know
3
fig bars, angel food cakes, orother types of low or nonfatcookies or cakes?
Almost always
Butter blended with oil or margarine
and safflower
Stick margarineRegular tub margarineDiet or light margarine (tub or liquid)
Butter blended with oil or margarineStick margarine
Sour cream
Regular tub margarineDiet or light margarine (tub or liquid)
PLEASE DO NOT WRITE IN THIS AREA
(Pam )
SAMPLE
4
Part II: Usual Food UseThese questions are about foods you ate during ______________________________________________.
Mediumserving
size M LS
HOW OFTEN DID YOU EAT THESE FOODS? AMOUNT?
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.
Cold cereals
CEREALS, BREADS, SNACKS
• 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.
2 piecesPancakes, French toast and waffles
➤
EXAMPLE: This person ate spaghetti with meat sauce every Saturday. They usually ate about 11/2 cups.
Spaghetti, lasagna, and otherpasta with tomato with meat sauce
Mediumserving
size M LS
AMOUNT?➤
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
2 pats or 2teaspoons
Butter or margarine on breads, cereals, pancakes, etc.
2 slices or
2 slices or1 medium
White breads, including bagels,rolls and English muffins
2 slices or1 medium
1 mediumMuffins, scones, croissantsand biscuits
2 Tbsp.
1 bar
1 bar
Jam, jelly, honey, syrup and sugar(including in coffee, tea and cereal)
Granola bars and cereal barssuch as Nutri-Grain Bars®
Sports or meal replacementbars such as Power Bars® andClif Bars®
Cooked cereals and grits
Milk on cereals
Whole grain breads and rolls
Plain tortillas as a side dish
Cornbread and corn muffins
(include flour and corn)3 small or
1 medium
1 large
1 21 / cups
1 21 / cups
1 21 / cups
/ cup3 4
SAMPLE
4
Liver, chicken liver andorgan meats
Ground meat, includinghamburgers and meatloaf
Beef, pork, ham and lamb
Canned tuna, tuna salad andtuna casserole
Regular hot dogs and sausagesuch as bratwurst and chorizo
Low or reduced fat hot dogsand sausage
Peanut butter, peanuts andother nuts and seeds
Regular crackers such as Ritz®
Low or nonfat crackers such as
Low or nonfat potato chips, tortillachips, corn chips and pretzels
medium
2 Tbsp.(spreads) or1/ cup (nuts)
medium
Regular potato chips, tortillachips, corn chips and puffs
PLEASE DO NOT WRITE IN THIS AREA
5
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
Mediumserving
size M LS
HOW OFTEN DID YOU EAT THESE FOODS? AMOUNT?➤
NEVER orless thanonce per
month
Plain popcorn (no butter) or lowfatmicrowave popcorn
Buttered or regular microwavepopcorn
Mediumserving
size M LS
AMOUNT?➤
2 eggs
3 strips or2 links
Bacon and breakfast sausage
1per
month
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
HOW OFTEN DID YOU EAT THESE FOODS?
NEVER orless thanonce per
month
1per
month
casserole
2 slices
All other lunch meat such asbologna, salami and Spam®
Lunch meats such as ham, turkeyand lowfat bologna
Fried chicken, includingnuggets and tenders
saltines
CEREALS, BREADS, SNACKS (continued)
medium®Triscuits an d rye crispbread
MEAT, FISH, EGGS
Whole grain crackers such as
and club crackers
12
4 handfuls or 1 med. bag
handfuls or 1 med. bag
8 handfuls
8 handfuls
12
12
2
2 hot dogs or4 ounces
2 hot dogs or
2 slices
4 ounces
1 can tuna
1 medium patty
or 2 cups
or 4 ounces
6 ounces
6 ounces
or 9 nuggets2 large pieces
Eggs (egg substitute, mark "NEVER")
SAMPLE
1 21 / cups
1 21 / cups
1 21 / cups
1 21 / cups
1 21 / cups
1 21 / cups
cups2
1 21 / cups
Burritos, tacos, tostadasand quesadillas
Pizza
Stew, pot pie, curries andcasseroles with meat or chicken
Dark fish (broiled or baked)such as salmon, mackereland bluefish
White fish (broiled or baked) suchas sole, halibut, snapper and cod
Shellfish, not fried (shrimp,lobster, crab and oysters)
Fried fish, fish sandwich and friedshellfish (shrimp and oysters)
Chicken and turkey (roasted,stewed, grilled or broiled)
6
pieces
1 sandwich
Mediumserving
size M LS
AMOUNT?➤
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
MEAT, FISH, EGGS (continued)
Mediumserving
size M LS
AMOUNT?➤
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
SPAGHETTI, MIXED DISHES, SOUPS
Chili with meat and beans
Spaghetti, lasagna and other pasta with tomato and meat sauce
Spaghetti and other pasta withtomato sauce (no meat)
Tofu, tempeh and productssuch as tofu hot dogs, soyburgers and tofu cheese
Asian-style (stir-fried) noodlesand rice such as chow mein,
or 1 burger
Enchiladas and tamales
Vegetable, minestrone andtomato soup
Cream soups such as chowders,potato and cheese
or
Pasta with oil, cheese, or creamsauce, including macaroni and
fried rice and Pad Thai
cheese
1 cup
4 small
6 ounces
2 large or
4 ounces or
6 ounces
6 ounces
3 slices
4 ounces,2 hot dogs
2 medium
2 medium
11 /
SAMPLE
1 21 / cups
1 21 / cups
1 21 / cups
1 21 / cups
Red peppers and red chilies
Green peppers and green chilies
Salad dressing (all types)
All other cheese (American,cheddar or cream), includingcheese used in cooking
Low or reduced fat cheese,including cheese used in cooking
Ramen noodle soup
Mediumserving
size M LS
AMOUNT?➤
Miso soup
Bean soups such as pea,lentil and black bean
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
SPAGHETTI, MIXED DISHES, SOUPS (continued)
Other soups such aschicken noodle
DAIRY PRODUCTS
Cottage cheese andricotta cheese
1/ cupshredded
1
cup shreddedor 2 Tbsp.
cream
Yogurt, all types except frozen
Mediumserving
size M LS
AMOUNT?➤
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
Mediumserving
size M LS
AMOUNT?➤
VEGETABLES and GRAINS
Mark all vegetables you ate, including in salads, mixed dishes, sandwiches and stir-fries.
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
Green salad (lettuce or spinach)
1 mediumor 4 slices
Fresh tomatoes
Carrots
1
/ cup
1/ cup
7
3 4
2 slices or2
22 slices, /
1/4 cup
2 cups
/ cup3
/ cup
4
2
2
6 ounces
SAMPLE
1 cup
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
/ cup3 4
and other fat added to
Potatoes (boiled, baked ormashed)
French fries, fried potatoesand hash browns
Avocado and guacamole
Onions and leeks
Green peas
Mediumserving
size M LS
AMOUNT?➤
Cauliflower, cabbage andBrussels sprouts
Green or string beans
Broccoli
Mark all vegetables you ate, including in salads, mixed dishes, sandwiches and stir-fries.
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
Corn and hominy
8
1/ cup
Cooked greens such as spinach,mustard greens and collards
Yams and sweet potatoes 1 medium
Winter squash such as acorn, butternut and pumpkin
Summer squash and zucchini
1/ mediumor 1/ cup
1 cloveFresh garlic, including in cooking
1 mediumor
Refried beans
Coleslaw
All other beans (baked, lima or chili without meat)
Potato, macaroni and pasta saladsmade with mayonnaise or oil
/ cup
PLEASE DO NOT WRITE IN THIS AREA
VEGETABLES and GRAINS (continued)
1 cupother whole grains (as a side dish)
Butter, margarine, sour cream
Brown rice, whole wheat pasta and
vegetables, potatoes and rice
grains (as a side dish)White rice, noodles and other
2 pats or 2
1 cup
teaspoons
3 4
2
1 cup
2
2
SAMPLE
1/ cup
Apples, applesauceand pears
Mayonnaise andmayonnaise-type spreads
Cheese sauce and cream sauce
Any other fruit such as grapes, fruitcocktail, pineapple and cherries
Dried fruit (other than apricots)such as raisins and prunes
Salsa (as dip or on foods)
9
Mediumserving
size M LS
AMOUNT?
1 orange or1/2 grapefruit
Oranges, grapefruit andtangerines (not juice)
Berries such as strawberriesand blueberries
1/ cup
2 mediumor 4 halvesApricots (fresh, canned or dried)
1 medium
1 mediumor 1/2 cup
FRUITS
1 mediumor 1/2 cup
Bananas
Peaches, nectarines and plums
➤
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
Meat gravies 1/ cup
1/ cup
Ketchup
2 Tbsp.
SAUCES and CONDIMENTS
Mediumserving
size M LS
AMOUNT?➤
1/ cup
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
1 41/2 mango
Cantaloupe, orange melonand mango (in season)
Watermelon and red melon
/ cup
2
2
4
2
2
/ cup3
/ melon or
4
3
1 large slice
4SAMPLE
1 cup
Chocolate, candy barsand toffee
Cookies and cakes
Pudding, custard and flan
Ice cream and milkshakes
Low or nonfat frozen dessertssuch as lowfat ice cream, frozenyogurt and sherbet
1 shake
cookies or 1 piece of
cake
SWEETS
1 regular baror
1 mediumpiece or
slice
Mediumserving
size M LS
AMOUNT?➤
Other candy such asLifesavers®, licorice andjelly beans
2-3per
month
1per
week
2per
week
3-4per
week
5-6per
week
1perday
2+perday
NEVER orless thanonce per
month
1per
month
HOW OFTEN DID YOU EAT THESE FOODS?
Doughnuts, pies and pastries
How often did you eat a servingof fruit? Do not count juices.
How often did you eat a servingof vegetables? Do not countpotatoes, salad or beans.
PLEASE ANSWER THESE THREE IMPORTANT QUESTIONS!
3-4per
week
5-6per
week
1perday
2perday
3perday
4perday
5+perday
NEVER orless thanonce per
week
1-2per
week
Note that the frequency headings are different.How often did you eat foods that werecooked in fat (pan-fried, sautéed, ordeep-fried)? Count all fat such asmargarine, butter, oil or lard.
10
PLEASE DO NOT WRITE IN THIS AREA
2 scoops
2 scoops or
3 med.
6 pieces or
4 pieces
25 jellybeans
SAMPLE
Other 100% fruit juice such asapple, grape and cranberry
Orange juice and grapefruit juice
Tomato juice, V-8® and othervegetable juices
11
Milk (all types) as a beverage
Coffee (not lattes or mochas) 1 cup
1 Tbsp.
BEVERAGES and ALCOHOL
1 cup
1 cup
1 cup
Milk, cream or creameradded to tea and coffee
Fruit drinks fortified with Vitamin C®
Mediumserving
size M LS
AMOUNT?➤
Note that the frequency headings are different.
1 cup
Meal replacement drinks and®
®1 cup
2-4per
week
1perday
6+perday
NEVER orless thanonce per
month
1-3per
month
HOW OFTEN DID YOU DRINK THESE BEVERAGES?
Latte, cappuccino, mochaor hot chocolate
Red wine
Beer (all types)
White or rosé wine
Regular soft drinks
Diet soft drinks
Water (tap, bottled or sparkling)
12 ouncecan or bottle
1 mediumglass (6 oz)
1 shot(11/2 oz) or
1 mixed drink
1 mediumglass (6 oz)
12 ouncesor 1 can
12 ouncesor 1 can
1 cup
Liquor and mixed drinks
1per
week
5-6per
week
2-3perday
4-5perday
THANK YOU!Please take a moment to fill in any questions you may have skipped.
