Coffee Drink Survey

1. Which of the below describes the coffee drink you are most likely to consume?

• Black coffee
• Black coffee with milk and/or sugar
• Decaf
• Iced coffee
• Frozen/blended coffee drink
• Latte
• Espresso
• Cappuccino
• Mocha
• I do not drink coffee/coffee drinks

2. Would you say that most of the coffee you drink is “instant” coffee?

• Yes
• No
• Not applicable (because I do not drink coffee drinks)

3. When you order a coffee drink at a coffee shop, do you typically order straight off the menu, or do you customize your order in any way?

• Customize
• Order straight off the menu
• Not applicable (because I do not drink coffee drinks)

4. How many coffee drinks (or cups of coffee) do you consume in a day?

• 0
• 1
• 2
• 3 or more

5. Have you been told by a doctor to lose weight and/or do you consider yourself overweight?

• Yes
• No

6. How would describe your sleep quality?

• Very poor
• Somewhat poor
• Neither poor nor good
• Somewhat good
• Very good

7. How is your energy level throughout the day?

• Very poor
• Somewhat poor
• Neither poor nor good
• Somewhat good
• Very good

8. How would you rate your overall health?

• Very poor
• Somewhat poor
• Neither poor nor good
• Somewhat good
• Very good

9. How do you respond to change?

• I prefer things to stay the way they are.
• I’m generally unaffected by change.
• I love change!