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