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Nutritional Epidemiology Branch
Sample Questionnaire
  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
a. Hamburgers or
cheeseburgers
(including fast food)		                     1 medium
or 4 oz.		      
Pan fried                      
Grilled or Barbecued                    
Oven-broiled                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
b. Beef Steaks                     4 oz.      
Pan fried                      
Grilled or Barbecued                    
Oven-broiled                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
c. Pork chops or ham steaks                     2 chops or
or 4 oz.		      
Pan fried                      
Oven-broiled                    
Baked or Roasted                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
d. Bacon                     2 strips      
Pan fried                      
Oven-broiled                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
e. Breakfast sausage                     2 links or 2 patties      
Pan fried                      
Grilled or Barbecued                    
Oven-broiled                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
f. Fried chicken                     2 small or 1 large piece      
Deep-fat fried or fast food                      
Pan fried                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
g. Chicken or turkey, including sandwiches                     2 small or 1 large piece      
Baked or Roasted                      
Stewed                    
Oven-broiled                    
Grilled or Barbecued                    
Cooked another way
(SPECIFY)
_______________		                    

 

  Never Less
Than
Once
Per
Month		 1
Per
Mo.		 2-3
Per
Mo.		 1
Per
Wk.		 2-3
Per
Wk.		 3-4
Per
Wk.		 5-6
Per
Wk.		 1
Per
Day		 2+
Per
Day		 Medium Serving Size
S M L
h. Gravy                     2 tbsp      
Made from meat drippings                      
Store-bought cans                    
Store-bought packets                    
Made another way
(SPECIFY)
_______________		                    

 

A hamburger or cheeseburger Rare  
Medium-rare  
Medium  
Medium-well  
Well-done  
Very well-done  
Don't know  
Did not eat  
Steak Rare  
Medium-rare  
Medium  
Medium-well  
Well-done  
Very well-done  
Don't know  
Did not eat  
Pork chop or ham steak Just until done  
Well-done  
Very well-done  
Don't know  
Did not eat  
Bacon Just until done  
Well-done  
Very well-done  
Don't know  
Did not eat  
Breakfast sausage Just until done  
Well-done  
Very well-done  
Don't know  
Did not eat  
Fried chicken Just until done  
Well-done  
Very well-done  
Don't know  
Did not eat  
Chicken Just until done  
Well-done  
Very well-done  
Don't know  
Did not eat