Food and Eating Habits Survey

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1. In a typical week, how often do you:
1. In a typical week, how often do you:6-7 days a week3-5 days a week1-2 days a weekrarely/never
Skip breakfast
Eat at a sit-down restaurant
Prepare homemade meals
2. In a typical week, how many meals and snacks do you eat?
2. In a typical week, how many meals and snacks do you eat?0123456
Number of meals on WEEKDAY
Number of snacks on WEEKDAY
Number of meals on WEEKEND
Number of snacks on WEEKEND
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.
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.Whole foodsProcessed foodsCombination of bothDon't know
Meals
Snacks
4. Select the answer that best describes your portion habits.
5. Select the statement that best describes your personal eating habits.
 
 
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? 
7. Looking back at the last month, about how often did you consume the following?
7. Looking back at the last month, about how often did you consume the following?6-7 days a week3-5 days a week1-2 days a weekrarely/never
Beef, pork or dark meat chicken
High-fat processed meats (bologna, salami, corned beef, hot dogs or bacon)
Fish
2-3 servings of milk, yogurt or cheese a day (or dairy alternatives)
Fried food such as fried chicken, chicken strips, French fries
Use butter in cooking or spread
Use shortening in cooking or spread
Use olive or canola oil in cooking or as a salad dressing
Use other vegetable oils in cooking or salad dressing: corn, soy bean, safflower
Cereals, granola bars, energy bars that are high in sugar
Baked goods or desserts such as cake, cookies, pastries, donuts, ice cream, muffins, candy or chocolate
High sodium processed foods liked canned soup or pasta, frozen/packaged meals (tv dinners, etc.) chips
Add salt to a meal that has already been prepared and seasoned
Alcohol (beer, wine, hard liquor or mixed drinks with hard liquor)
Juice, soda, lemonade, sports drinks, energy drinks, sweetened coffeee or tea, smoothies, or other sugar-sweetened beverages
Drink 8 glasses of water daily (includes unsweetened herbal teas)
8. Do you read food labels when you purchase packaged foods?
9. Do you feel confident that you can effectively read food labels to select nutritious foods?
10. Do you feel confident that you can prepare and cook healthy meals at home?
11. How would you describe your household's food environment?
12. When you eat out, how often do you?
12. When you eat out, how often do you?All of the timeMost of the timeOccasionallyRarely/never
Eat fast food
Order large portions
Eat everything that was ordered
Leave with a bag of leftovers
Share a meal with someone
Leave food on the plate
Order dessert
13. When eating out, how often do you drink these beverages?
13. When eating out, how often do you drink these beverages?All of the timeMost of the timeOccasionallyRarely/never
Water
Sodas (diet or regular)
Sweetened beverages (juice, flavored milk, coffee drinks, etc.)
Plain milk (or dairy alternative)
Unsweetened coffee or tea
Alcohol
14. Below is a list of signs of emotional or stress triggered hunger. Check the circle that applies to your frequency.
14. Below is a list of signs of emotional or stress triggered hunger. Check the circle that applies to your frequency.All of the time/Most of the timeOccasionallyRarely/never
Your desire to eat comes on rapidly like an on/off switch
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
Your hunger increases with certain emotions, especially those causing stress
You can't think through your food options, rather you grab something and can think straight only after you have eaten them
Your hunger drives you to eat without tasting your food
You feel guilt before and/or after eating