Food and Eating Habits Survey

1. In a typical week, how often do you:

Space Cell	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Skip breakfast	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Eat at a sit-down restaurant	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Prepare homemade meals	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never

2. In a typical week, how many meals and snacks do you eat?

Space Cell	0	1	2	3	4	5	6
Number of meals on WEEKDAY	0	1	2	3	4	5	6
Number of snacks on WEEKDAY	0	1	2	3	4	5	6
Number of meals on WEEKEND	0	1	2	3	4	5	6
Number of snacks on WEEKEND	0	1	2	3	4	5	6

3. Are the majority of your meals and snacks made up of whole or processed foods?

Whole foods are unprocessed foods in their original form: fresh fruits and vegetables, fresh meats, unflavored dairy products, whole grains.

Processed foods are pre-made or packaged foods that consist of refined grains, added sugar, salt or preservatives.

Space Cell	Whole foods	Processed foods	Combination of both	Don't know
Meals	Whole foods	Processed foods	Combination of both	Don't know
Snacks	Whole foods	Processed foods	Combination of both	Don't know

4. Select the answer that best describes your portion habits.

• I eat portion sizes that are just right for me
• I eat portions that are small for me
• I eat portions that are large for me
• I eat portions that are excessive for me

5. Select the statement that best describes your personal eating habits.

• I eat until I am full, getting additional servings if needed
• I fill my plate one time only and eat until I have finished what is on my plate
• I fill my plate one time and stop eating when I am full
• I fill my plate with what I think is the right amount of food which makes me feel less than full

6. The plate model diagram shown above demonstrates that a healthy plate is made up of 1/4 whole grains, 1/4 protein and 1/2 fruits and vegetables. How often do your meals follow this plate model? 

• All of the time
• Most of the time
• 1-2 times a week
• Occasionally
• Almost never

7. Looking back at the last month, about how often did you consume the following?

Space Cell	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Beef, pork or dark meat chicken	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
High-fat processed meats (bologna, salami, corned beef, hot dogs or bacon)	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Fish	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
2-3 servings of milk, yogurt or cheese a day (or dairy alternatives)	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Fried food such as fried chicken, chicken strips, French fries	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Use butter in cooking or spread	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Use shortening in cooking or spread	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Use olive or canola oil in cooking or as a salad dressing	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Use other vegetable oils in cooking or salad dressing: corn, soy bean, safflower	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Cereals, granola bars, energy bars that are high in sugar	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Baked goods or desserts such as cake, cookies, pastries, donuts, ice cream, muffins, candy or chocolate	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
High sodium processed foods liked canned soup or pasta, frozen/packaged meals (tv dinners, etc.) chips	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Add salt to a meal that has already been prepared and seasoned	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Alcohol (beer, wine, hard liquor or mixed drinks with hard liquor)	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Juice, soda, lemonade, sports drinks, energy drinks, sweetened coffeee or tea, smoothies, or other sugar-sweetened beverages	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never
Drink 8 glasses of water daily (includes unsweetened herbal teas)	6-7 days a week	3-5 days a week	1-2 days a week	rarely/never

8. Do you read food labels when you purchase packaged foods?

• yes
• no

9. Do you feel confident that you can effectively read food labels to select nutritious foods?

• yes
• no

10. Do you feel confident that you can prepare and cook healthy meals at home?

• yes
• no

11. How would you describe your household's food environment?

• Extremely healthy
• Mostly healthy
• A mix between healthy and unhealthy
• Mostly unhealthy
• Extremely unhealthy

12. When you eat out, how often do you?

Space Cell	All of the time	Most of the time	Occasionally	Rarely/never
Eat fast food	All of the time	Most of the time	Occasionally	Rarely/never
Order large portions	All of the time	Most of the time	Occasionally	Rarely/never
Eat everything that was ordered	All of the time	Most of the time	Occasionally	Rarely/never
Leave with a bag of leftovers	All of the time	Most of the time	Occasionally	Rarely/never
Share a meal with someone	All of the time	Most of the time	Occasionally	Rarely/never
Leave food on the plate	All of the time	Most of the time	Occasionally	Rarely/never
Order dessert	All of the time	Most of the time	Occasionally	Rarely/never

13. When eating out, how often do you drink these beverages?

Space Cell	All of the time	Most of the time	Occasionally	Rarely/never
Water	All of the time	Most of the time	Occasionally	Rarely/never
Sodas (diet or regular)	All of the time	Most of the time	Occasionally	Rarely/never
Sweetened beverages (juice, flavored milk, coffee drinks, etc.)	All of the time	Most of the time	Occasionally	Rarely/never
Plain milk (or dairy alternative)	All of the time	Most of the time	Occasionally	Rarely/never
Unsweetened coffee or tea	All of the time	Most of the time	Occasionally	Rarely/never
Alcohol	All of the time	Most of the time	Occasionally	Rarely/never

14. Below is a list of signs of emotional or stress triggered hunger. Check the circle that applies to your frequency.

Space Cell	All of the time/Most of the time	Occasionally	Rarely/never
Your desire to eat comes on rapidly like an on/off switch	All of the time/Most of the time	Occasionally	Rarely/never
You are easily influenced by the food environment. For example, you will eat sweets that are lying around the office, accept sweets offered by colleague or friend	All of the time/Most of the time	Occasionally	Rarely/never
Your hunger increases with certain emotions, especially those causing stress	All of the time/Most of the time	Occasionally	Rarely/never
You can't think through your food options, rather you grab something and can think straight only after you have eaten them	All of the time/Most of the time	Occasionally	Rarely/never
Your hunger drives you to eat without tasting your food	All of the time/Most of the time	Occasionally	Rarely/never
You feel guilt before and/or after eating	All of the time/Most of the time	Occasionally	Rarely/never