This survey is about ALL the food the young person participating in the study ate in the past 7 days. Remember to include foods eaten at home, foods eaten at a friend’s house, foods eaten in restaurants, 'fast foods', foods from snack machines, at the movies, and any other food or
beverage.
There are no right or wrong answers. It is very important that we learn what you actually eat, not what you think you should eat. Please answer each question as best you can; estimate if you aren't sure.
SERIAL #
PLEASE DO NOT WRITE IN THIS AREAK IDS' F OOD Q UESTIONNAIRE
PATIENT #
OFFICE USE ONLY
The next pages are about all the foods the study participant (the young person) ate in the past 7 days.
PLEASE READ THE DIRECTIONS ON THE NEXT PAGE. Please answer every question on the survey.
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• Use only a number 2 pencil, NOT a pen
• Fill in the circles completely
• Erase completely if you make any changes
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✓
Correct Mark Incorrect Marks
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PATIENT INITIALS
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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0 1 2 3 4 5 6 7 8 9
Review Copy
Do not use without permission
1 egg
2 eggs
3 eggs Just a
bite
How many eggs do you usually eat in one day?
Last week, did you eat any pancakes?
Last week, did you eat any eggs, including breakfast sandwiches with eggs?
Last week, did you eat any hot cereal, like oatmeal?
How many do you usually have
in one day?
See pictures.
Which bowl?
1 2 3
YES NO
How many days?
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➞
USUAL AMOUNT EATEN IN ONE DAY?
YES NO
How many days?
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YES NO
How many days?
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2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY
If YES, "How many days in the past 7 days?"
EXAMPLE
B C D
4
NOTE: There is no A-size bowl.
Now, please take out the portion size pictures, and begin the food questions.
How to fill out the Food Questionnaire
Now, please tell us about the foods on these pages.
Did you eat it in the past 7 days?
If the food was not eaten in the past 7 days, mark "No" and go to the next food. In the EXAMPLE, the young person did not have any pancakes last week.
If the food was eaten, answer these two questions:
1. "How many days in the past 7 days did you eat it?"
Mark the box that shows the number of days the food was eaten.
If you are not sure, it is okay to guess.
In the EXAMPLE, the child had EGGS two days in the past 7 days, and HOT CEREAL on one day.
2. "How much" of the food was eaten on the days you ate it.
(The "how much" means how big a serving you usually ate.) The pictures will help for some foods.
In the EXAMPLE, the young person usually had a C-sized bowl of hot cereal, And ONE EGG on the days he ate eggs,
Review Copy
Do not use without permission
Page 3 Think about every time you ate anything in the past 7 days, either at home or at school, at a friend's house, at
a restaurant, from a snack machine.... You can tell us you didn't eat it at all in the past 7 days, or one day last week, two days last week, 3-4 days, 5-6 days, or every day. So,...
If YES,
Did you eat any cold cereal, like Corn Flakes, Frosted Flakes or any other kind?
Last week, did you have milk on cereal?
Did you eat any hot cereal, like oatmeal?
See pictures.
Which bowl?
B C D
"How many days in the past 7 days"
B C D
See pictures.
Which bowl?
USUAL AMOUNT EATEN IN ONE DAY?
How many?
1/2 1 2 3
Last week, did you eat any eggs, including breakfast sandwiches with eggs?
Did you eat any sausage, including breakfast sandwiches with sausage?
1 egg
2 eggs
3 eggs Just a
bite
Did you eat any pancakes, waffles or French toast?
Last week, did you have any breakfast bars, or granola bars?
Did you have any bread or toast, including sandwiches?
How many eggs do you usually eat in one day?
Last week, did you eat any biscuits or muffins?
Last week, did you have any cornbread, corn muffins, corn tortillas?
Last week, did you have any flour tortillas?
How many pieces?
How many?
How many?
1/2 1 2 3
1/2 1 2-3 4+
1/2 1 2 3
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY
1/2 1 2 3
1 2 3-4
How many?
How many slices usually in
one day?
Remember what you ate at home, at school, at a friend's house, from snack machines, or from a restaurant.
YES NO
How many days?
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➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
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➞ YES
NO
How many days?
➞
➞
See pictures.
Which bowl?
No portion size
5 or more
YES NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
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YES NO
How many days?
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➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞
1 DAY
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY
B C D
Review Copy
Do not use without permission
SERIAL #
PLEASE DO NOT WRITE IN THIS AREAPage 4
Did you eat any hamburgers or cheeseburgers?
Last week, did you eat any hot dogs or corn dogs?
How much usually in one
day?
1/2
small burger
1 small burger
1 large burger
How many did you have in one
day?
YES NO
How many days?
➞
➞
USUAL AMOUNT EATEN IN ONE DAY?
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY
If YES, "How many days in the past 7 days?"
When you have burgers, are they usually cheeseburger
or plain (no cheese)? Always cheeseburger Sometimes cheeseburger Never cheeseburger
1/2 1 2 3
Last week, did you have any hamburger buns, hotdog buns or bagels?
1/2 1 2 3
Last week, did you have any tacos or burritos?
How many hot dogs?
How much usually in one
day? 1/2 1 2 3
Did you eat any mixed dish with chicken, like chicken and gravy,
chicken pot pie, or in frozen dinners? A B C D
Last week, did you eat any fish, like fish sandwiches, fish sticks, or any kind of fish?
How much?
A B C D
Did you eat any mixed dishes with beef, like beef & noodles, beef pot pie, Hamburger Helper, stew, casserole etc.?
How much?
A B C D
Did you eat any spaghetti, ravioli or
lasagna with tomato sauce? How much?
A B C D
Did you eat any macaroni and cheese? How much?
A B C D
Last week, did you eat any pizza, or pizza pockets?
1/2 1 2 3
How many slices?
1 DAY
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY YES
NO
How many days?
➞
YES NO
How many days?
➞
YES NO
How many days?
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YES NO
How many days?
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YES NO
How many days?
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YES NO
How many days?
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YES NO
How many days?
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YES NO
How many days?
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YES NO
How many days?
➞
➞
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➞
2 large burgers
Remember what you ate at home, at school, at a friend's house, from snack machines, or from a restaurant.
See pictures.
How much?
Review Copy
Do not use without permission
Remember what you ate at home, at school, at a friend's house, from snack machines, or from a restaurant.
1 2
SERIAL #
PLEASE DO NOT WRITE IN THIS AREAFC FB BC BB
FORM NUMBER VERSION MULTI-PART
NUMBER SIG
COLOR NUMBER INITIALS / DATE
Last week, did you eat any baked beans, chili with beans, refried beans, pinto beans, or red Mexican beans?
Did you eat any greens, including
spinach, mustard greens, or collards?
See pictures.
How much?
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY
Did you have any kind of potatoes, like French fries, tater tots, mashed or baked potatoes?
Last week, did you eat any dressing or stuffing, like "Stove-Top"?
Did you eat any vegetable soup, vegetable beef soup, tomato soup, or any cream soups?
Did you eat any rice?
Page 5
If YES, "How many days in the past 7 days?"
USUAL AMOUNT EATEN IN ONE DAY?
B C D
A
B C D
A
B C D
A
B C D
A
B C D
A
B C D
A YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞
Did you have gravy, like on mashed potatoes or on rice?
See pictures.
How much?
See pictures.
How much?
See pictures.
How much?
See pictures.
How much?
See pictures.
How much?
No portion size YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞
1 DAY
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY
Review Copy
Do not use without permission
USUAL AMOUNT EATEN IN ONE DAY?
Did you have any yogurt?
(Not frozen yogurt)
Last week, did you have any nachos with cheese?
Did you have any snacks like potato chips, Doritos, popcorn, etc.?
Last week, did you have any sour cream, or dips made with sour cream?
Did you have any ice cream, ice cream bars or frozen yogurt?
Did you have any cookies?
Did you have any cake, cupcakes, doughnuts, Tasty Cake, Ho-Ho's, or Twinkies?
Did you have any pudding?
How much?
1 small
If YES,
B C D
A
Page 6
How many?
How many cookies?
B C D
A
B C D
A
B C D
A
B C D
How much?
How much, in the whole day?
See pictures.
Which bowl?
How much?
How many bars?
1/2 carton
How many slices of cheese?
Last week, did you have any sliced cheese, Cheese Whiz, cream cheese, or grilled cheese sandwiches?
1 carton
YES NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞
"How many days in the past 7 days?"
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY
1/2 1 2 3
2 cartons
3 cartons
How much, in the whole day?
1 2-3 4-5 6+
1/2 1 2 3
1 medium 1
large 2 large
Last week, did you have any chocolate candy, like candy bars, Hugs, or M & Ms?
YES NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞ YES
NO
How many days?
➞
➞
1 DAY
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY Remember what you ate at home, at school, at a friend's
house, from snack machines, or from a restaurant.
Review Copy
Do not use without permission
FC FB BC BB
FORM NUMBER VERSION MULTI-PART
NUMBER SIG
COLOR NUMBER INITIALS / DATE
If YES, "How many days in the past 7 days?"
Page 7
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY Last week, did you drink any sodas like
Coke, Sprite, Dr. Pepper or any other soft drinks? Include both regular and diet.
How many bottles or cans on those days?
Did you drink any other real fruit juices like apple juice or grape juice?
(Remember juice boxes)
HOW MANY GLASSES ON THE DAYS YOU DRANK IT?
YES NO
How many days?➞
➞
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more)
1 2 3-4 5+
How many bottles or glasses?
1 2 3 4
Last week, did you drink any Sunny Delight, Kool-Aid, Hi-C, or fruit punch?
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more)
Last week, did you drink any real orange juice? (Don't count orange sodas)
How many glasses or cartons?
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more)
When you drink orange juice, is it usually a kind that has extra calcium added?
Always calcium fortified Sometimes calcium fortified
Never calcium fortified Don't know
YES NO
How many days?➞
➞ How many
glasses or
cartons? 1 2 3 4
1 2 3 4
When you drink those juices, are they usually a kind that has extra calcium added?
Always calcium fortified Sometimes calcium fortified
Never calcium fortified Don't know
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more) YES
NO
How many days?➞
➞
YES NO
How many days?➞
➞ Remember what you ate at home, at school, at a friend's house, from snack machines, or from a restaurant.
Review Copy
Do not use without permission
In the past week, did you take any vitamin pills, like One-a-Day or Flintstones? No Yes
THANK YOU VERY MUCH FOR PARTICIPATING IN THIS IMPORTANT RESEARCH!
SERIAL #
PLEASE DO NOT WRITE IN THIS AREAHow many glasses or cartons?
1 2 3 4
If YES, "How many days in the past 7 days?"
1 2 3 4
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY 1
DAY HOW MANY GLASSES
ON THE DAYS YOU DRANK IT?
Page 8
MM245776-1 654321 Printed in U.S.A.
How many glasses or
cans?
YES NO
How many days?
➞
➞ Did you drink any milk, chocolate milk
or hot chocolate? (Don't include milk on cereal). Remember at home, at school, after school, as a snack, at dinner.
What size glass? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more) YES
NO
How many days?
➞
➞ Did you drink any Instant Breakfast
milkshakes like Carnation, diet shakes like Slimfast, or liquid supplements like Ensure?
1 2 3 4
How many glasses?
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more) Last week did you drink any milkshakes? YES
NO
How many days?
➞
➞
What size glass or can? A (6 oz) B (8 oz) C (12 oz) D (16 oz or more)
In the past week, did you take any calcium pills? No Yes
Yes No
In the past week, did you take any antacid pills, like Tums or Rolaids?
Last week, was your diet typical of the way you usually eat? (Check one or more)
YES NO, I was sick NO, I ate more than usual NO, I ate less than usual NO, another reason (What?)
Block Kids_Calcium© 2002 BDDS, Phone (510)-704-8514 www.nutritionquest.com
1 DAY
2 DAYS
3-4 DAYS
5-6 DAYS
EVERY DAY Remember what you ate at home, at school, at a friend's
house, from snack machines, or from a restaurant.
