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Please select one option for each question:
The type of spread we use is
Butter
Stick margarine
Soft tub margarine
None
The type of fat we use in cooking is
Butter, lard, meat drippings
Shortening, margarine
Safflower, soybean, sunflower, corn oil
Olive, canola oil
The number of egg yolks I eat in a week, including those in baking is
More than 6
5-6
4-5
4 or less
The kind of milk I drink/use on cereal
Whole
2%
1%
Skim
The number of times I eat regular cheese
More than once per day
Usually once per day
4-6 times per week
3 times or less per week
The amount of cheese I usually have in one serving
4 ounces
3 ounces
2 ounces
1 ounce or less
5.The number of times I eat dried peas, lentils, and dried beans is
Less than once per week
Once per week
2 times per week
3 times or more per week
If you eat meat: The number of times I eat red meat, luncheon meat, or pork is
2-3 times per day
1-2 times per day
Usually once per day
Less than once per day
If you are a vegetarian: The number of times I eat protein-rich foods as dried peas, beans, lentils, tofu
Less than once per day
Usually once per day
2 times per day
3 times per day
The number of times I eat high-fat snacks and sweets (chips, cookies, nuts, cakes, candy bars, pies, donuts, and ice cream)
Daily
5-6 times per week
3-4 times per week
2 times per week or less
The number of times I use convenience foods (canned or frozen dinners, canned soup or vegetables, packaged rice or noodles)
Daily
3-6 times per week
2 times per week
Once per week or less
The number of times a day I eat fruit or drink juice
None
1 time
2 times
3 or more
The number of servings of citrus fruits and juices, peppers, strawberries, tomatoes I eat
None
1-2 per week
3-5 per week
1 or more per day
The number of servings of vegetables I have per day
None
1
2-3
4 or more
The number of servings of dark leafy green and deep yellow or orange vegetables I have per we
None
1-2
3-4
5 or more
The number of servings of bread, cereal, rice, and pasta I have per day
None
1-3
4-6
7 or more
The way I add salt to foods is
Always in cooking and before tasting food
Always in cooking and sometimes at the table
Some in cooking and none at the table or vice versa
None in cooking or at the table
I normally choose low fat or nonfat varieties of yogurt, cheese, cottage cheese, frozen desserts and milk.
Yes
No
When I eat cheese, I use it as a protein source or substitute for meat, and not as a snack.
Yes
No
I choose whole-grain breads, whole-grain cereals and brown rice.
Yes
No
I choose lower-fat meats such as extra lean hamburger, ground turkey and chicken, fish and seafood, round steak, pork loin, sirloin, and chuck roast over higher-fat varieties such as luncheon meat, bacon, hot dogs, sausage, steak, and ground beef.
Yes
No
I eat fried foods and fast-food burgers, fries, and high-fat desserts less than once a week.
Yes
No
I consume no alcohol or less than one alcoholic beverage per day (1 drink equals 12 oz. Beer, 4 oz. Wine, 1 oz. Hard liquor)
Yes
No
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