Baseline Survey

Out, Proud and Healthy Fitness Project

19116_ID Out Proud and Healthy Fitness-Baseline Survey

Baseline Survey

OMB: 0990-0411

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Form Approved

OMB No. 0990-

Baseline OWH Out, Proud, and Healthy (OPAH) Exp. Date XX/XX/20XX

Baseline Survey

Stress Jackson Heart Study

We are interested in the amount of stress that you have experienced over the past 12 months. Please rate the stress in different parts of your life (in column 1) by CIRCLING the letter in the columns on the right that best represents your level of stress in the past 12 months.

Over the Past 12 months, how much stress did you experience:

Not Stressful

Mildly Stressful

Moderately Stressful

Very Stressful

Does Not Apply

1. In your job? (This would include feeling overworked, hassled at work, job insecurity, etc.)

2. In your relationships with others? (This would include your marriage, friendships, dealing with relatives, etc.)

3. Related to living in your neighborhood? (This would include crime, traffic, events affecting your personal safety, etc.)

4. Related to caring for others? (This would include caring for an elderly parent or relative, caring for children, etc.)

5. Related to legal problems? (This would include dealing with lawyers, judges, or other court officials, being accused or convicted of crime, etc.)

6. Related to medical problems? (This would include personal health problems or illness in the family, availability of health care, etc.)

7. Related to racism and discrimination? (This would include feeling mistreated or discriminated against at work, in a restaurant, at the grocery store, etc).

8. Related to meeting basic needs? (This would include housing, buying food, paying bills, etc.)

The Lesbian Internalized Homophobia Scale

Circle your degree of agreement with the following statements from

1 = strongly disagree to 7 = strongly agree.

When reading the following, you can substitute “queer women” for lesbians or bisexual women.

	1 Strongly Disagree	2	3	4 Neutral	5	6	7 Strongly Agree
I try not to give signs that I am a lesbian/bisexual woman. I am careful about the way I dress; the jewelry I wear; and the places, people and events I talk about.	1	2	3	4	5	6	7
I am comfortable being an “out” lesbian or bisexual woman. I want others to know and see me as a lesbian or bisexual woman.	1	2	3	4	5	6	7
I wouldn’t mind if my boss knew that I was a lesbian/bisexual woman.	1	2	3	4	5	6	7
It is important for me to conceal the fact that I am a lesbian/bisexual woman.	1	2	3	4	5	6	7
I feel comfortable talking to my heterosexual friends about my everyday home life with my female partner/lover or my everyday activities with my lesbian/bisexual friends.	1	2	3	4	5	6	7
I am not worried about anyone finding out that I am a lesbian/bisexual woman.	1	2	3	4	5	6	7
I live in fear that someone will find out that I am a lesbian/bisexual woman.	1	2	3	4	5	6	7
I feel comfortable talking about homosexuality in public.	1	2	3	4	5	6	7
I do not feel the need to be on guard, lie, or hide my lesbianism/bisexuality to others.	1	2	3	4	5	6	7
If my peers knew of my lesbianism/bisexuality, I am afraid that many would not want to be friends with me.	1	2	3	4	5	6	7
I could not confront a straight friend or acquaintance if she or he made a homophobic or heterosexist statement to me.	1	2	3	4	5	6	7
I feel comfortable discussing my lesbianism/bisexuality with my family.	1	2	3	4	5	6	7
I don’t like to be seen in public with queer women who look “too butch” or are “too out” because others will then think I am a lesbian.	1	2	3	4	5	6	7
I act as if my female lovers are merely friends.	1	2	3	4	5	6	7
When speaking of my female lover/partner to a straight person, I often use neutral pronouns so the sex of the person is vague.	1	2	3	4	5	6	7
When speaking of my female lover/partner to a straight person, I change pronouns so that others will think I’m involved with a man rather than a woman.	1	2	3	4	5	6	7
I hate myself for being attracted to other women.	1	2	3	4	5	6	7
I am proud to be a lesbian/bisexual woman.	1	2	3	4	5	6	7
I feel bad for acting on my lesbian desires.	1	2	3	4	5	6	7
As a lesbian/bisexual woman, I am loveable and deserving of respect.	1	2	3	4	5	6	7
I feel comfortable being a lesbian/bisexual woman.	1	2	3	4	5	6	7
If I could change my sexual orientation and become heterosexual, I would.	1	2	3	4	5	6	7
I don’t feel disappointed in myself for being a lesbian/bisexual woman.	1	2	3	4	5	6	7
Being a lesbian/bisexual woman makes my future look bleak and hopeless.	1	2	3	4	5	6	7
Just as in other species, female homosexuality is a natural expression of sexuality in human women.	1	2	3	4	5	6	7
Female homosexuality is a sin.	1	2	3	4	5	6	7
Female homosexuality is an acceptable lifestyle.	1	2	3	4	5	6	7
Children should be taught that being gay is a normal and healthy way for people to be.	1	2	3	4	5	6	7
Lesbian couples should be allowed to adopt children the same as heterosexual couples.	1	2	3	4	5	6	7
Growing up in a lesbian family is detrimental for children.	1	2	3	4	5	6	7
Lesbian lifestyles are viable and legitimate choices for women.	1	2	3	4	5	6	7
I feel comfortable with the diversity of women who make up the lesbian/bisexual community.	1	2	3	4	5	6	7
If some lesbian/bisexual women would change and be more acceptable to the larger society, lesbians and bisexual women as a group would not have to deal with so much negativity and discrimination.	1	2	3	4	5	6	7
I wish some lesbians wouldn’t “flaunt” their lesbianism. They only do it for shock value and it doesn’t accomplish anything positive.	1	2	3	4	5	6	7
Lesbians are too aggressive.	1	2	3	4	5	6	7
My feelings toward other lesbian/bisexual women are often negative.	1	2	3	4	5	6	7
I frequently make negative comments about other lesbian/bisexual women.	1	2	3	4	5	6	7
I have respect and admiration for other lesbian/bisexual women.	1	2	3	4	5	6	7
I can’t stand lesbian/bisexual women who are too “butch.” They make queer women as a group look bad.	1	2	3	4	5	6	7

Lubben Social network Scale*

How many family members do you see or hear from at least once a month?

None

3-4

5-8

Nine or more

How many family members do you feel at ease with that you can talk about private matters?

None

3-4

5-8

Nine or more

How many family members do you feel close to such that you could call on them for help?

None

3-4

5-8

Nine or more

How many of your friends do you see or hear from at least once a month?

None

3-4

5-8

Nine or more

How many friends do you feel at ease with that you can talk about private matters?

None

3-4

5-8

Nine or more

How many friends do you feel close to such that you could call on them for help?

None

3-4

5-8

Nine or more

Perceived Stress Scale

The following questions ask you about your feelings and thoughts DURING THE LAST MONTH. In each case, check the box indicating how often you felt or thought that way.

	Very often	Fairly often	Some times	Almost never	Never
In the last month, how often have you been upset because of something that happened unexpectedly?
In the last month, how often have you felt that you were unable to control the important things in your life?
In the last month, how often have you felt nervous and “stressed?”
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you found that you could NOT cope with all things that you had to do?
In the last month, how often have you been able to control irritations in your life?
In the last month, how often have you felt that you were on top of things?
In the last month, how often have you been angered because of things that were outside of your control?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Connor-Davidson Resiliency Scale (CD-RISC)*

Please indicate how much you agree with the following statements as they apply to you over the last month. If a particular situation has not occurred recently, answer according to how you think you would have felt.

	Not true at all	Rarely true	Sometimes true	Often true	True nearly all the time
I am able to adapt when changes occur	1	2	3	4	5
I can deal with whatever comes my way	1	2	3	4	5
I try to see the humorous side of things when I am faced with problems	1	2	3	4	5
Having to cope with stress can make me stronger	1	2	3	4	5
I tend to bounce back after illness, injury, or other hardships	1	2	3	4	5
I believe I can achieve my goals, even if there are obstacles	1	2	3	4	5
Under pressure, I stay focused and think clearly	1	2	3	4	5
I am not easily discouraged by failure	1	2	3	4	5
I can usually find something to laugh about	1	2	3	4	5
I think of myself as a strong person when dealing with life’s challenges and difficulties	1	2	3	4	5
I am able to handle unpleasant or painful feelings like sadness, fear and anger	1	2	3	4	5

Discrimination Questionnaire

The next set of questions has to do with things that may have happened to you and the way you have been treated over your lifetime. We know from other research that experiences of unfair treatment related to race, age, gender, culture, religion, physical appearance, sexual orientation, etc., are common and very important to consider in understanding people’s health. These questions will give a picture of the various kinds of experiences of people in this study. There are no right or wrong answers; only your experiences. Please remember that any information you provide is strictly confidential and will never be identified with you as an individual. Let’s start with experiences you may have had on a day-to-day basis.”

1. To the right of each statement put an X in the column that most closely matches how often this has occurred.

How often do you have the following experiences?	Several times a day [1]	Almost every day [2]	At least once a week [3]	A few times a month [4]	A few times a year [5]	Very rarely [6]	Never [0]	Don’t Know [9]
1a. You are treated with less respect or courtesy than other people
1b. You receive poorer service than others at restaurants
1c. People act as if they think you are not smart
1d. People act as if they are afraid of you
1e. People act as if they think you are dishonest
1f. People act as if they think you are not as good as they are
1g. You are called names, insulted, threatened or harassed

If all responses in Item 1 are “NEVER,” then go to Question 3

2. Thinking over these experiences, what do you think is the main reason for this treatment?

Your age

Your gender

Your race

Your cultural or ethnic background

Your height, weight or physical appearance

Your religion

Your sexual orientation

Some other reason for discrimination

Don’t know

3. The next questions are about what has happened over your lifetime because of issues such as your race, ethnicity, gender, age, religion, physical appearance, sexual orientation, or other characteristics.

	YES	NO	Don’t know
3a. Have you ever felt unfairly treated at school or during training? (For example, you were discouraged by a teacher or advisor from seeking higher education, were denied a scholarship, etc.)
3b. Have you ever felt unfairly treated in getting a job? (For example, you were not hired or you were told you could not apply.).
3c. Have you ever felt unfairly treated at work?
3d. Have you ever felt unfairly treated in getting housing or finding a place to live? (For example, you were prevented from renting or buying a home in the neighborhood you wanted or you were prevented from remaining in a neighborhood because neighbors made life so uncomfortable.)
3e. Have you ever felt unfairly treated in getting resources or money? (For example, you were denied a bank loan, a credit card or some other form of credit.)
3f. Have you ever felt unfairly treated in getting medical care? (For example, you were denied or provided inferior medical care, you were made to wait long periods of time before getting care or you could not get care from a medical specialist such as a heart doctor.)
3g. Have you ever felt unfairly treated on the street or in a public place? (For example, you were hassled by the police, were the target of public ridicule, etc.)
3h. Have you ever felt unfairly treated in getting services? (For example, you were denied or provided inferior service by a plumber, in a restaurant, the grocery store, or by some other service provider.)

If all responses in Question 3 are “NO,” then you are done with this questionnaire

4. Thinking about the most recent of the above experiences over your lifetime, what was the main reason for the discrimination you experienced?

Your age

Your gender

Your race

Your cultural or ethnic background

Your height, weight or physical appearance

Your religion

Your sexual orientation

Some other reason for discrimination

Don’t know

5. Thinking back over these types of experiences, compared with when you were younger, are the experiences more frequent, less frequent, or about the same?

More frequent

Less frequent

About the same]

Don’t know

6. When you have had experiences like the above over your lifetime, would you say they have been very stressful, moderately stressful, or not stressful?

Very stressful

Moderately stressful

Not stressful

Don’t know

7. Overall, how much harder has your life been because of discrimination; would you say a lot, some, a little, or not at all?

A lot

Some

A little

Not at all

Don’t know

Multidimensional Body-Self Relations Questionnaire

You are asked to indicate the extent to which each statement pertains to you personally. Read each statement carefully and decide how much it pertains to you personally. Using the scale below, indicate your answer by entering it to the left of the number of the statement.

1=Definitely disagree

2=Mostly disagree

3=Neither agree or disagree

4=Mostly agree

5=Definitely agree

____1. Before going out in public, I always notice how I look

____2. I am careful to buy clothes that will make me look my best

____3. My body is sexually appealing

____4. I like my looks just the way they are

____5. I check my appearance in a mirror whenever I can

____6. Before going out, I usually spend a lot of time getting ready

_____7. Most people would consider me good-looking

_____8. It is important that I always look good

_____9. I use very few grooming products

_____10. I like the way I look without my clothes

_____11. I am self-conscious if my grooming isn’t right

_____12. I usually wear whatever is handy without caring how it looks

_____13. I like the way my clothes fit me

_____14. I don’t care what people think about my appearance

_____15. I take special care with my hair grooming

_____16. I dislike my physique

_____17. I am physically unattractive

_____18. I never think about my appearance

_____19. I am always trying to improve my physical appearance

International Physical Activity Questionnaire (IPAQ) – Short*

Shape51

We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?

_____ days per week

Shape53 No vigorous physical activities Skip to question 3

How much time did you usually spend doing vigorous physical activities on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.

_____ days per week

Shape56 No moderate physical activities Skip to question 5

How much time did you usually spend doing moderate physical activities on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

5. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

_____ days per week

Shape59 No walking Skip to question 7

How much time did you usually spend walking on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

During the last 7 days, how much time did you spend sitting on a week day?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Stage of Exercise

For each statement, please put a check (√) in one of the boxes to the right that best matches what you have done or think you will do.	YES	NO
I currently exercise regularly and have done so for longer than 6 months
I currently exercise regularly but I have only begun doing so within the last 6 months
I currently exercise some, but not regularly
I currently do not exercise, but I am thinking about starting to exercise in the next 6 months
I currently do not exercise and I do not intend to start exercising in the next 6 months

Exercise Self-Efficacy

Whether you exercise or not, please rate how confident you are that you could really motivate yourself to do things like these consistently, for at least six months.

How sure are you that you can do these things?	I know I cannot	Maybe I can	I know I can
Get up early, even on weekends, to exercise
Stick to your exercise program after a long, tiring day at work
Exercise even though you are feeling depressed
Set aside time for a physical activity program; that is, walking, jogging, swimming, biking, or other continuous activities for at least 30 minutes, 5 times a week
Continue to exercise with others even though they seem too fast or slow for you
Stick to your exercise program when undergoing a stressful life change (e.g., death of the family, moving)
Attend a party only after exercising
Stick to your exercise program when your family/friends are demanding more time from you
Stick to your exercise program when you have household chores to attend to
Stick to your exercise program when you have excessive demands at work
Stick to your exercise program when social obligations are very time consuming
Read or study less in order to exercise more

Barriers to Exercise Scale

The following items reflect situations that are listed as common reasons for preventing individuals from participating in exercise sessions or, in some cases, dropping out. Using the scales below please indicate how confident you are that you could exercise in the event that any of the following circumstances were to occur.

Please indicate the degree to which you are confident that you could exercise in the event that any of the following circumstances were to occur by circling the appropriate %. To the right of each statement, put an ‘X’ in the column with the response that most closely matches your own, remembering that there are no right or wrong answers.

I believe I could exercise 5 times per week (at least 150 minutes of moderate physical activity) for the next 3 months if:

Statement	Not at all confident 0%	10%	20%	30%	40%	Moderately confident 50%	60%	70%	80%	90%	Highly confident 100%
The weather was very bad (hot, humid, rainy, cold).
I was bored by the program or activity.
I was on vacation.
I was not interested in the activity.
I felt pain or discomfort when exercising.
I had to exercise alone.
It was not fun or enjoyable.
It became difficult to get to the exercise location.
I don’t like the particular activity program that I was involved in.
My schedule conflicted with my exercise session.
I felt self-conscious about my appearance when I exercised.
An instructor does not offer me any encouragement.
I was under personal stress of some kind.

Motive for Physical Activities Questionnaire

The following is a list of reasons why people engage in physical activities, sports and exercise. Keeping in mind your primary physical activity or sport, respond to each question (using the scale given) on the basis of how true that response is for you.

1-7 scale; 1= not at all true for me, 7= very true for me

____1. I do not engage in any physical activities, sports or exercise (skip to the next section)

___ 2. Because I want to be physically fit.

___ 3. Because it’s fun.

___ 4. Because I like engaging in activities which physically challenge me.

___ 5. Because I want to obtain new skills.

___ 6. Because I want to look or maintain weight so I look better.

___ 7. Because I want to be with my friends.

___ 8. Because I like to do this activity.

___ 9. Because I want to improve existing skills.

___ 10. Because I like the challenge.

___ 11. Because I want to define my muscles so I look better.

___ 12. Because it makes me happy.

___ 13. Because I want to keep up my current skill level.

___ 14. Because I want to have more energy

___ 15. Because I like activities which are physically challenging.

___ 16. Because I like to be with others who are interested in this activity.

___ 17. Because I want to improve my cardiovascular fitness.

___ 18. Because I want to improve my appearance.

___ 19. Because I think it’s interesting.

___ 20. Because I want to maintain my physical strength to live a healthy life.

___ 21. Because I want to be attractive to others.

___ 22. Because I want to meet new people.

___ 23. Because I enjoy this activity.

___ 24. Because I want to maintain my physical health and well-being.

___ 25. Because I want to improve my body shape.

___ 26. Because I want to get better at my activity.

___ 27. Because I find this activity stimulating.

___ 28. Because I will feel physically unattractive if I don’t.

___ 29. Because my friends want me to.

___ 30. Because I like the excitement of participation.

___ 31. Because I enjoy spending time with others doing this activity.

Veterans RAND 36 Item Health Survey (VR-36)*

Instructions: This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities.

Please answer every question by filling in one circle on each line. If you are unsure about how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

EXCELLENT

VERY GOOD

GOOD

FAIR

POOR

2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

	YES, LIMITED A LOT	YES, LIMITED A LITTLE	NO, NOT LIMITED AT ALL
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports?	0	0	0
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?	0	0	0
c. Lifting or carrying groceries?	0	0	0
d. Climbing several flights of stairs?	0	0	0
e. Climbing one flight of stairs?	0	0	0
f. Bending, kneeling, or stooping?	0	0	0
g. Walking for than a mile?	0	0	0
h. Walking several blocks?	0	0	0
i. Walking one block?	0	0	0
j. Bathing or dressing yourself?	0	0	0

3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

	NO, NONE OF THE TIME	YES, A LITTLE OF THE TIME	YES, SOME OF THE TIME	YES, MOST OF THE TIME	YES, ALL OF THE TIME
a. Cut down the amount of time you spent on work or other activities.	0	0	0	0	0
b. Accomplished less than you would like.	0	0	0	0	0
c. Were limited in the kind of work or other activities.	0	0	0	0	0
d. Had difficulty performing the work or other activities (for example, it took extra effort).	0	0	0	0	0

4. During the past 4 weeks, have you had any of the following problems with your work or other daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

	NO, NONE OF THE TIME	YES, A LITTLE OF THE TIME	YES, SOME OF THE TIME	YES, MOST OF THE TIME	YES, ALL OF THE TIME
a. Cut down the amount of time you spent on work or other activities.	0	0	0	0	0
b. Accomplished less than you would like.	0	0	0	0	0
c. Were limited in the kind of work or other activities.	0	0	0	0	0

5. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

NOT AT ALL

SLIGHTLY

MODERATELY

QUITE A BIT

EXTREMELY

6. How much bodily pain have you had during the past 4 weeks?

NONE

VERY MILD

MILD

MODERATE

SEVERE

VERY SEVERE

7. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house work)?

NOT AT ALL

A LITTLE BIT

MODERATELY

QUITE A BIT

EXTREMELY

8. These questions are about how you feel and how things have been with you during the past 4 weeks.

For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks:

	ALL OF THE TIME	MOST OF THE TIME	A GOOD BIT OF THE TIME	SOME OF THE TIME	A LITTLE OF THE TIME	NONE OF THE TIME
a. Do you feel full of pep?	0	0	0	0	0	0
b. Have you been a very nervous person?	0	0	0	0	0	0
c. Have you felt so down in the dumps that nothing could cheer you up?	0	0	0	0	0	0
d. Have you felt calm and peaceful?	0	0	0	0	0	0
e. Did you have a lot of energy?	0	0	0	0	0	0
f. Have you felt downhearted and blue?	0	0	0	0	0	0
g. Did you feel worn out?	0	0	0	0	0	0
h. Have you been a happy person?	0	0	0	0	0	0
i. Did you feel tired?	0	0	0	0	0	0

9. During the past 4 weeks, how much of the time has your physical health or emotional problems

interfered with your social activities (like visiting with friends, relatives, etc.)?

ALL OF

THE TIME

MOST OF

THE TIME

SOME OF

THE TIME

A LITTLE OF

THE TIME

NONE OF

THE TIME

10. Please choose the answer that best describes how true or false each of the following statements is for you.

	DEFINITELY TRUE	MOSTLY TRUE	NOT SURE	MOSTLY FALSE	DEFINITELY FALSE
a. I seem to get sick a lot easier.	0	0	0	0	0
b. I am as healthy as anybody I know.	0	0	0	0	0
c. I expect my health to get worse.	0	0	0	0	0
d. My health is excellent.	0	0	0	0	0

Now we’d like to ask you some questions about how your health may have changed.

11. Compared to one year ago, how would you rate your physical health in general now?

MUCH

BETTER

SOMEWHAT

BETTER

ABOUT THE

SAME

SOMEWHAT

WORSE

MUCH

WORSE

12. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

MUCH

BETTER

SOMEWHAT

BETTER

ABOUT THE

SAME

SOMEWHAT

WORSE

MUCH

WORSE

NHANES Weight History

These next questions ask about your height and weight at different times in your life.

How tall are you without shoes?

_____ _____

feet Inches

How much do you weigh without clothes or shoes?

[If you are currently pregnant, how much did you weigh before your pregnancy?]

_________

pounds

Do you consider yourself now to be… (Check one)

Overweight.

Underweight

About the right weight

Would you like to weigh… (Check one)

More.

Less

Stay about the same

How much would you like to weigh?

_________

pounds

How much did you weigh a year ago?

[If you were pregnant a year ago, how much did you weigh before your pregnancy?]

_________

pounds

6a. If you lost 10 pounds in the past year, was the decrease between your current weight and your weight a year ago because you tried to lose weight?

No (go to Q8)

Yes (go to Q7)

Don’t Know (go to Q8)

6b. If you did not lose 10 pounds in the past year, during the past 12 months, did you try to lose weight or not gain weight?

No (go to Q8)

Yes (go to Q7)

Don’t Know (go to Q8)

How did you try to lose weight? (check all that apply)

___Ate less food (amount)

___Switched to foods with lower calories

___Ate less fat

___Ate fewer carbohydrates

___Exercised

___Skipped meals

___Ate “Diet” foods or products

___Used a liquid diet formula such as Slimfast or Optifast

___Joined a weight loss program, such as weight watchers, Jenny Craig,

Overeaters Anonymous, or Tops

___Followed a special diet such as Dr. Atkins, South Beach,other high protein

or low carbohydrate diet, cabbage soup diet, ornish, nutrisystem,

body-for-life

___Took diet pills prescribed by a doctor

___Took other pills, medicine, herbs, or supplements not needing a

prescription

___Started to smoke or began to smoke again

___Took laxatives or vomited

___Drank a lot of water

___Ate more fruits, vegetables, salads

___Ate less sugar, candy, sweets

___Changed eating habits (didn’t eat late at night, ate several small meals a

day)

___Ate less junk food or fast food

___Joined online weight loss program such as My Fitness Pal, Spark People

___Other, please specify

In the past 12 months, did you seek help from a personal trainer, dietitian, nutritionist,

doctor or other health professional to lose weight?

No (go to Q9)

Yes (go to Q8a)

Don’t Know (go to Q9)

8a Was that a …(Check all that apply)

___personal trainer

___dietitian

___nutritionist

___doctor

___other health professional

___don’t know

9. Have you ever tried to lose weight?

No (go to Q10)

Yes (go to Q9a)

Don’t Know (go to Q10)

9a. How much weight did you lose in your most successful attempt ever to lose weight? This question refers only to deliberate attempts to lose weight; it does not refer to weight loss because of illness, side effects of medication, stress, or other unintended causes.

__________

Pounds

10. How much did you weigh 10 years ago. If you don't know your exact weight, please make your best guess.] [If you pregnant, how much did you weigh before your pregnancy?

__________

Pounds

11. How much did you weigh at age 25? [If you don't know your exact weight, please make your best guess.] [If you pregnant, how much did you weigh before your pregnancy?

__________

Pounds

12. How tall were you at age 25? [If you don't know your exact height, please make your best guess.]

_____ _____

feet Inches

13. What is the most you ever weighed? [Do not include any times when you were pregnant.]

__________

Pounds

14. How old were you then? [If you don't know your exact age, please make your best guess.]

_______ years old

Eating Out and Food/Drink Consumption Questions

Next, we have some questions about your eating habits and about meals. Meals means breakfast, lunch and dinner.

In general, how healthy is your overall diet? Would you say …..

Excellent

Very good

Good

Fair

Poor

Don’t Know

During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

___________

Number of meals

How many of those meals did you get from a fast-food or pizza place?

___________

Number of meals

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did you eat “ready to eat” foods from the grocery store? [Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.]

Circle the unit

___________ per day or per week or per month

Number of times

During the past 30 days, how often did you eat frozen meals or frozen pizzas?

Circle the unit

___________ per day or per week or per month

*During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.