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pdfAppendix J: Self Administered Student Questionnaire and Food Diary
Students in non-FFVP schools will be given a version of the Student Questionnaire that excludes
questions 16a through 19. There will be no difference in the 1-Day Food Record for students at
FFVP and non-FFVP schools.
OMB clearance # 0584‐xxxx
Expiration date: xx‐xx‐20xx
For office use only
ID: _______________
Self Administered Student Questionnaire
Please answer the questions below. Please check the box or fill in the blanks.
This is not a test! There are no right or wrong answers. We want to know about you and what
you like to eat.
If you have any questions, please ask the interviewer.
Many of these questions are about the foods you ate or drank during the past 7 days
(weekdays and weekend days). Think about all meals, snacks, and drinks you had each day
and evening for all 7 days. Be sure to include food you ate at home, school, restaurants and
anywhere else.
1. During the past 7 days, how many times did you drink any punch, Kool-Aid, sports drinks,
energy drinks, vitamin water, or other fruit-flavored drinks?
Do NOT count 100% fruit juice or soda.
Mark only ONE box.
1
2
3
4
I did not drink fruit-flavored drinks during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB number. The valid OMB control number for this information collection is 0584-xxxx. The time required to complete this
information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the Food and Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, VA 22302.
2. During the past 7 days, how many times did you drink any regular (NOT diet) sodas or soft
drinks?
Mark only ONE box.
1
2
3
4
I did not drink regular soda during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
3. During the past 7 days, how many times did you drink any diet sodas or soft drinks?
Mark only ONE box.
1
2
3
4
I did not drink diet soda during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
4. During the past 7 days, how many times did you drink 100% fruit juices such as orange
juice, apple juice, or grape juice?
Do NOT count fruit punch, Kool-Aid, sports drinks, energy drinks, vitamin water or other fruit-flavored drinks.
Mark only ONE box.
1
2
3
4
I did not drink 100% fruit juice during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
2
5. During the past 7 days, how many times did you eat fruit? Include fresh, canned, frozen and
dried fruit.
Do NOT count fruit juice.
Mark only ONE box.
1
2
3
4
I did not eat fruit during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
6. During the past 7 days, how many times did you eat green salad?
.
Mark only ONE box.
1
2
3
4
I did not eat green salad during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
7. During the past 7 days, how many times did you eat French fries, fried potatoes, or chips?
Chips are potato chips, tortilla chips, Cheetos, puffs, corn chips, or other snack chips.
Mark only ONE box.
1
2
3
4
I did not eat French fries, fried potatoes or chips during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
3
8. During the past 7 days, how many times did you eat other salty snacks? Other salty snacks
include cheese nibs, chex mix, gold fish crackers, Ritz, or other snack chips.
Mark only ONE box.
1
2
3
4
I did not eat other salty snacks during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
9. During the past 7 days, how many times did you eat other kinds of potatoes?
Do NOT count French fries, fried potatoes, or potato chips.
Mark only ONE box.
1
2
3
4
I did not eat potatoes during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
10. During the past 7 days, how many times did you eat carrots? Include cooked or raw carrots.
Mark only ONE box.
1
2
3
4
I did not eat carrots during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
4
11. During the past 7 days, how many times did you eat other vegetables? Include fresh, canned,
and frozen vegetables.
Do NOT count green salad, potatoes, or carrots.
Mark only ONE box.
1
2
3
4
I did not eat other vegetables during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
12. During the past 7 days, how many times did you eat a frozen dessert? A frozen dessert is a
cold, sweet food like ice cream, sherbet, milk shake, frozen yogurt, an ice cream bar or a Popsicle.
Mark only ONE box.
1
2
3
4
I did not eat frozen desserts during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
13. During the past 7 days, how many times did you eat sweet rolls, doughnuts, Pop Tarts,
Twinkies, Ho Hos, cookies, brownies, pies or cake?
Mark only ONE box.
1
2
3
4
I did not eat things like cookies during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
5
14. During the past 7 days, how many times did you eat any candy? Count chocolate candy,
candy bars, jelly bellies, gummies and Lifesavers.
Do NOT count cookies or gum.
Mark only ONE box.
1
2
3
4
I did not eat candy during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
5
6
7
2 times per day
3 times per day
4 or more times per day
15. In a usual school week (weekdays), how often do you eat the following school
meals? Mark only ONE box for each statement.
Less than
once a week
or never
1 to 2 times a
week
3 to 4 times a
week
Every day
A. I usually eat the school lunch…
B. I usually bring lunch from home…
C. I usually eat the school
breakfast….
1
1
1
2
2
2
3
3
3
4
4
4
6
Your school offers free fresh fruit and vegetable snacks BETWEEN meals.
16a. When they are offered, how often do you usually take the free fresh FRUIT
snack? Mark only ONE box.
1
2
3
4
5
Every time offered
Most times offered
Occasionally
Never
Haven’t seen it offered
16b. When they are offered, how often would you take the free fresh VEGETABLE
snack? Mark only ONE box.
1
2
3
4
5
Every time offered
Most times offered
Occasionally
Never
Haven’t seen it offered
16c. If you take the free fresh FRUIT snack when it is offered, how much of it do you
usually eat? Mark only ONE box.
1
2
3
I usually eat all of it
I usually eat most of it
I usually eat some of it
I don’t usually eat any of it
4
5
I don’t’ usually take the free fresh fruit
7
16d. If you take the free fresh VEGETABLE snack when it is offered, how much of it
do you usually eat? Mark only ONE box.
1
2
3
I usually eat all of it
I usually eat most of it
I usually eat some of it
I don’t usually eat any of it
4
5
I don’t usually take the free fresh vegetable
16e. If you do not take the fruit or vegetable snacks when they are offered, why
not? Check ALL that apply.
1
2
3
4
5
I already take them every time they are offered
I don’t like fruits and vegetables
I’m not hungry when they are offered
I don’t like the look of the fruits and vegetables offered
Another reason (please write why): ____________________________
17a. Have you heard or seen any information around school about the free fresh fruit
and vegetable snacks? Mark only ONE box.
1
2
Yes
No
If no, skip to question 18
8
17b. If you answered yes to question 17a, where did you see or hear the
information? Check ALL that apply.
1
2
3
4
5
School cafeteria staff
Announcement over the loud speaker
Poster around school
Teacher/classroom
Other (please describe where) __________________________________
18. How much do you agree or disagree with the following statements?
Mark only ONE box for each statement.
I agree
very
much
I agree
a
little
I disagree
a
little
I disagree
a
lot
A. I eat more fruits and vegetables
on days when free fresh fruits
and vegetable snacks are given
at school than on other days
B. The free fresh fruits and
vegetables they give us for school
snacks look good and taste good.
C. I wish they would give us different
kinds of fresh fruits and
vegetables to eat for school
snacks.
D. On days when I eat a free fresh
fruit or a vegetable snack at
school, I don’t eat other kinds of
snacks.
E. I hope the free fresh fruit and
vegetable snack program
continues at our school.
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
9
19. If you could change anything about the free fresh fruit and vegetable snack
program, what changes would you make?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
20. How many servings of fruits and vegetables do you think are healthy to eat each
day? Mark only ONE box.
1
2
3
4
5
At least 1 serving
1-2 servings
3-4 servings
5 servings or more
Don’t know
21. How much do you agree or disagree with each of the following statements?
Mark only ONE box for each statement.
I agree
very
much
I agree
a
little
I disagree
a
little
I disagree
a
lot
A. I like most fruits
B. I like most vegetables
C. I like to try new kinds of fruits
D. I like to try new kinds of
vegetables
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
10
22. For each fresh fruit or vegetable, mark how much you like it. Even if you can’t eat
one of these foods now (for example, you have braces or some other reason) answer
whether you like or don’t like it. Mark only ONE box for each fruit or vegetable.
A lot
A little
Don’t like it
A. Apples
B. Bananas
C. Strawberries
D. Kiwi Fruits
E. Oranges
F. Pears
G. Grapes
H. Cantaloupe
I. Peaches
J. Pineapple
K. Plums
L. Watermelon
M. Nectarines
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Don’t Know
Never
tasted
4
4
4
4
4
4
4
4
4
4
4
4
4
11
22. Continued
For each fresh fruit or vegetable, mark how much you like it.
Mark only ONE box for each fruit or vegetable.
A lot
A little
Don’t like it
N. Blueberries
O. Tomatoes
P. Carrots
Q. Bell peppers
R. Zucchini
S. Celery
T. Broccoli
U. Cauliflower
V. Cucumbers
W. Lettuce
X. Snow peas
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
Don’t Know
Never
tasted
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
You are nearly finished! Just a couple of questions about you…
12
23. Are you Hispanic or Latino?
1
2
Yes
No
24. How do you describe yourself? Mark all that apply
1
American Indian or Alaska Native White
2
Asian
3
Black or African American
4
Native Hawaiian or Other Pacific Islander
5
White
25. What language do you use with your parents most of the time?
1
English
2
Spanish
3
Other (please describe) ________________________________________
Thank you for completing this questionnaire!
13
OMB clearance # 0584-xxxx
Expiration date: xx-xx-20xx
d
o
o
F
y
y
M
r
a
i
D
Your Name:
Start Time:
Stop Time:
Please ask your parent
or caregiver to help you
fill in the details of foods
and drinks that you have
at home.
Please bring your
completed diary with
you to school tomorrow.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The
valid OMB control number for this information collection is 0584-xxx. The time required to complete this information collection is estimated to average 60 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Food and
Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, VA 22302.
Directions
� In your booklet, write everything you eat and drink. Begin
now until you go to bed tonight. Include anything you eat or
drink tomorrow morning. Keep going up to the time to stop
recording. This time is posted on the front cover.
� Each time you eat or drink, write the time.
� Write down the place where your food was eaten. This might
be home, friend’s house, school, restaurant, etc.
� Write one food or drink on each line.
� Describe your food and drinks. Give brand names. List
ingredients in homemade dishes. Ask an adult to help you at
home.
� Describe how your food was prepared. This might be fried,
baked, broiled, grilled, boiled, microwaved, etc.
� Describe your fruits and vegetables. This might be fresh,
canned, dried or frozen.
� Describe how your vegetables are cooked. This might be
fried, baked broiled, grilled, boiled or microwaved.
� Measure your food and drinks. Use the cups, spoons, ruler or
shapes in your booklet.
� Tell us how much you actually eat or drink, even if you did
not finish.
� Write down any snacks, candy or drinks you have.
1
Date
/
Month
/
Day
Year
Day of the week
Boy
Age
Girl
years old
Grade
Name of school
Teacher’s Name
2
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
10 00
______:______
12 30
______:______
12 30
______:______
12 30
______:______
12 30
______:______
3 15
______:______
What?
Food and Drink
(Write type, brand, description)
Blueberries, fresh
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
1/3 cup
Source? S H FH FF/P R DK
Other ____________________
AM/PM
Grilled cheese sandwich –
white bread, American cheese
Bread – 4 inches square
Cheese – 3 inches square
Left the crusts
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
Chocolate milk, 1% fat
1 carton 8 fl oz of milk
Pears, canned
Source? S H FH FF/P R DK
Other ____________________
4 oz - one carton
Source? S H FH FF/P R DK
Other ____________________
Nestle crunch bar
B L D S
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
2 1/2 x 1 x 1/2 inch - 1 oz on wrapper
B L D S
Where Eaten? S H FH FF/P R DK
AM/PM
Strawberry vanilla yogurt
(Yoplait Lite)
B L D S
Where Eaten? S H FH FF/P R DK
AM/PM
½ cup
Left about half of it
B L D S
B L D S
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
3
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
6 00
______:______
6 00
______:______
7 30
______:______
What?
Food and Drink
(Write type, brand, description)
Spaghetti with Meat Sauce
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
Spaghetti noodles - ¾ cup
Meat sauce - ½ cup
Grated cheese 1tbsp
Ate it all!
(Do not write here)
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
Coke, diet
Honey Nut Cheerios,
Kelloggs
Where Eaten? S H FH FF/P R DK
12 fl oz – 1 can
Source? S H FH FF/P R DK
Other ____________________
AM/PM
3/4 cup
1% milk
7 fl oz
B L D S
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
7 30
______:______
B L D S
B L D S
Where Eaten? S H FH FF/P R DK
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
4
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
5
d
My Foro
y
a
i
D
T ip!
Coder ____________________________
Interviewer ________________________
p pictures
or shape
Use your cups, spoons, ruler
ch you ate or drank.
to help you decide how mu
l size of your food
Or you may draw the actua
on the back of this page.
Participant ID ______________________
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
6
7
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
8
9
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
10
11
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
12
13
My Food Diary
T ip!
Use your cups, spoo
ns, ruler or shape pi
ctures to help you de
much you ate or dran
cide how
k. Or you may draw
the actual size of yo
on the back of this
ur ffood
page.
d
Write 1 food per line. Do not write in shaded (grey) areas.
When?
Time
(Write in Time)
What?
Food and Drink
(Write type, brand, description)
How Much?
Where?
Amount I Ate or Drank
(Write in cups, inches, ounces from packages)
(Do not write here)
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
Where Eaten? S H FH FF/P R DK
______:______
Source? S H FH FF/P R DK
Other ____________________
AM/PM
B L D S
14
15
Describe each food and drink. Record as much information as you can. Ask
your parent or an adult to help you. Even if you cannot describe a food, be
sure to write its name in your diary.
Drinks: Type? Amount? Any ice?
• Juice: 100%/Juice Drinks/Juice Blends
° Brand name, flavor
° Regular or low calorie, added calcium or other
fortified
° Juice or drink?
• Milk
° White, chocolate, other flavor
° Whole, 2%, 1%, skim (nonfat)
• Soda/Sparkling Water/Vitamin Waters
° Brand name
° Sweetened/flavored or unsweetened/unflavored
° Regular or diet
° Water, tap or bottled
• Sports drinks, Energy drinks
° Brand
Rice/Pasta/Noodles/Spaghetti
° Rice: white, brown, convenience mix brand (Rice
A Roni)
° Pasta/noodles: regular, or whole grain
° Any additions? (butter, oil, gravy, sauce, cheese)
Fast Foods
° Name of restaurant
° Name of food (Big Mac, BK Broiler, Pepperoni
Pizza,
° Add anything or take anything off? (ketchup,
mustard, lettuce, tomato,
° Size of order (small, medium, large)
Breads/Bagels/Biscuits/Muffins
Dessert or Snacks
Mixed Dishes/Recipes
• Candy/Chocolate
° Brand name and/or description
° Weight from package
° Bars: package size (funsize, snacksize, kingsize)
° Type: white, whole wheat, cornbread, bagel
° Store bought (give brand name), bakery, or
homemade
° Any additions? (butter, margarine, mayonnaise,
jelly)
° Muffins: bran, carrot, blueberry, chocolate chip
° Measure diameter of top and bottom and give
height
° Tortilla: corn, flour, or wheat, plain or fried,
diameter
° Name of dish or recipe, (spaghetti, macaroni
and cheese, Hamburger Helper)
° List and describe all or main ingredients
° Preparation (baked, fried, stir fried)
° Any sauce? (tomato, cream, soy)
° Any vegetables? Type?
° Any meat? Type?
° Noodles or rice or potato?
° Any additions? (sour cream, hot sauce, cheese)
Sandwiches
° Kind of sandwich (grilled cheese, tuna,
hamburger)
° List and describe all ingredients
° Type of bread? (roll, hamburger bun, Wonder
bread slice, white or whole wheat)
° Any condiments? (ketchup, mayonnaise, butter)
° Any vegetables? (lettuce, tomato, pickle,
onions)
° Any meat or cheese? Type?
• Cookies/Cakes/Donuts/Pastries
° Brand name, description, measurements
° Type? (chocolate chip, yellow cake,)
° Store bought (give brand name), bakery,
homemade – mix or scratch?
° Any frosting? (flavor; from mix, scratch or can)
° Number of cake layers, shape, measurements
• Ice Cream/Frozen Yogurt/Frozen Dessert
° Brand name, regular or softserve
° Flavor, any additions? (nuts, sprinkles, whipped
cream, sauce, etc.)
° Regular or lowfat, yogurt or ice cream
• Pies
° Type? (fruit, cream, custard, sweet potato)
° Crust (dough, graham cracker) homemade or
store bought, single or double crust
° Any additions? (ice cream, whipped cream)
Frozen Meals
° Brand name and description of foods
° Package weight and amount eaten
16
Fats/Salad Dressings/Spreads
• Butter, Margarine, Lard, Pork Fat
° Brand name
° Butter: regular, whipped, butter/margarine
blend
° Margarine: stick, tub or squeeze, regular, light,
fat free or ultra-light
• Oil and Shortening
° Brand name
° Oil: type? (canola, soybean, vegetables, etc.)
° Shortening: regular or butter flavor
• Salad Dressing
° Type? (French, Honey Mustard, Italian, Ranch,
etc.)
° Store bought (give brand name) or homemade
(give ingredients if known)
° Regular, low calorie, lowfat, or nonfat
• Mayonnaise/Spreads
° Brand name
° Type? (real or maynnaise-type; regular, lowfat
or nonfat)
Snacks
• Chips/Snackfoods/Crackers
° Brand name, package weight ,or measure with
cups
° Type? (potato, tortilla, rice cakes, pork rinds,
cheese curls, etc.) and brand name
° Regular or baked?
° Any additions? (dips, cheese sauce, salsa, etc.)
• Popcorn
° Type? (air, oil, microwaved, or commercial
packaged)
° Microwaved/commercial packaged: give brand
name, regular or light
° Plain, butter flavored, or butter/margarine
added?
° Weight from bag, number of cups
Meats/Chicken/Fish
• Meat
° Type? (beef, pork, veal, etc.)
° Cut (ribs, chops, steak, ground, pigs feet, liver)
° Marinated or basted with fat (type?)
° Fat eaten or trimmed away
° Preparation (fried, baked, grilled, broiled)
° Give measurements including thickness, with or
without bone
° Any additions? (steak sauce, garlic butter,
gravy, etc.)
° Luncheon meats: deli or store bought (give
brand name); regular, thin sliced or shaved;
regular, lowfat or fat free
° Hot dogs (beef, pork, turkey, chicken; regular,
lowfat or fat free)
• Chicken
° Piece (breast, wing, thigh, drumstick, etc.) or
type meat (light or dark)
° Breading or coating, skin eaten or removed,
with or without bone
° Marinated or basted with fat (type?)
° Preparation (fried, baked, stewed, barbequed,
pan or deep fried, etc.)
° For nuggets give number eaten, for chicken
strips give number and measurements
° Any additions? (BBQ sauce, gravy, etc.)
° Skin eaten? (If removed, before or after
cooking?)
Burritos/Tacos
°
°
°
°
°
Kind of burrito (bean, meat, veggie)
List and describe all ingredients
Type of tortilla (flour, wheat, corn, fried or plain)
Size of tortilla (6 inches, 10 inches, 12 inches)
Any sauces (salsa, cream, cheese, sour cream,
guacamole)
° Any vegetables (corn, lettuce, tomato, avocado,
zucchini squash, bell peppers, onions)
° Any meat (chicken, pork, ground beef, shredded
beef, fish, shrimp)
° Any cheese? Type?
Vegetables/Beans
° Type vegetable: squash, corn, greens, okra,
broccoli, etc.
° Type beans: pinto, kidney, blackeyed peas,
refried, etc.
° Preparation (boiled, microwaved, steamed, stir
fried,)
° Canned, fresh, frozen
° Seasoned with meat? (bacon, Hamhocks,
fatback, etc.)
° Fat in preparation or at tables (type?)
° Potatoes: with or without skin, french fries, tater
tots, etc.
• Fish/Shellfish
° Type? (catfish, sole, salmon, shrimp, bass, etc.)
° Fresh, frozen, canned (oil or water pack,
drained or rinsed)
° Breaded or batter dipped, marinated or basted
with fat (type?)
° Preparation (fried, baked, broiled, steamed)
° Crab: type? (Alaskan, blue, Softshell, etc.) give
number of legs or whole crabs; any additions?
(tartar sauce, melted butter, cocktail sauce,
etc.)
17
Describe how much you ate or drank. Use these shapes to help. Or you may
draw the size of the food on a blank page in this Diary.
Use your ruler or these pictures
to help you with sizes.
2 inches
across
5 inches across
1 ½ inch
across
4 inches across
3 inches
across
1
inch
across
18
Describe how much you ate or drank. Use the cups, spoons, and the drawings
of the ruler or shape pictures to help. Or you may draw the size of the food on
a blank page in this Diary.
1
2
3
4
5
6
7
8
¼ ½ ¾ 1 ¼ ½ ¾ 2 ¼ ½ ¾ 3 ¼ ½ ¾ 4 ¼ ½ ¾ 5 ¼ ½ ¾ 6 ¼ ½ ¾ 7 ¼ ½ ¾ 8
How
wide?
How
wide?
Square
How
long?
Rectangle
How
thick?
How
thick?
How
long?
How
wide?
How
wide?
Wedge
Cylinder
How
tall?
How
thick?
How
long?
19
| File Type | application/pdf |
| File Title | Microsoft Word - AppendixJ Student survey diary 1-7-10.docx |
| Author | NicholsonJ |
| File Modified | 2010-06-08 |
| File Created | 2010-05-17 |