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 |