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Sample Questionnaire

 NeverLess
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 ServingSize
SML
a. Hamburgers or
cheeseburgers
(including fast food)
          1 medium
or 4 oz.
   
Pan fried           
Grilled or Barbecued          
Oven-broiled          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
b. Beef Steaks          4 oz.   
Pan fried           
Grilled or Barbecued          
Oven-broiled          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
c. Pork chops or ham steaks          2 chops or
or 4 oz.
   
Pan fried           
Oven-broiled          
Baked or Roasted          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
d. Bacon          2 strips   
Pan fried           
Oven-broiled          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
e. Breakfast sausage          2 links or 2 patties   
Pan fried           
Grilled or Barbecued          
Oven-broiled          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
f. Fried chicken          2 small or 1 large piece   
Deep-fat fried or fast food           
Pan fried          
Cooked another way
(SPECIFY)
_______________
          

 

 NeverLess
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 ServingSize
SML
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)
_______________
          

 

 NeverLess
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 ServingSize
SML
h. Gravy          2 tbsp   
Made from meat drippings           
Store-bought cans          
Store-bought packets          
Made another way
(SPECIFY)
_______________
          

 

A hamburger or cheeseburgerRare 
Medium-rare 
Medium 
Medium-well 
Well-done 
Very well-done 
Don't know 
Did not eat 
SteakRare 
Medium-rare 
Medium 
Medium-well 
Well-done 
Very well-done 
Don't know 
Did not eat 
Pork chop or ham steakJust until done 
Well-done 
Very well-done 
Don't know 
Did not eat 
BaconJust until done 
Well-done 
Very well-done 
Don't know 
Did not eat 
Breakfast sausageJust until done 
Well-done 
Very well-done 
Don't know 
Did not eat 
Fried chickenJust until done 
Well-done 
Very well-done 
Don't know 
Did not eat 
ChickenJust until done 
Well-done 
Very well-done 
Don't know 
Did not eat