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pdfForm Approved
OMB No. 0920‐0904
Exp. Date 11/30/2014
Food Questionnaire
This questionnaire was developed by Block Dietary Data System (© BDDS, Berkely CA, 510-704-8514) and modified by the University of South
Carolina, Arnold School of Public Health, Center for Research in Nutrition and Health Disparities.
Permission for use must be obtained from both organizations.
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia
30333; ATTN: PRA (0920‐0904).
SEARCH 3 Cohort Study ‐ Food Questionnaire revised 1‐03‐12
This survey is about all the food you ate over the past week. This includes food eaten
anywhere like at home, school, a friend’s house, and in restaurants. There are no right or
wrong answers. Think about all the foods you ate over the past week and not just what you
think you should be eating.
Please, answer the questions by filling the bubbles using a sharp pencil. Do not use a pen.
Answer each question as best you can. If you are unsure, estimate what you ate. A guess is
better than leaving a blank. Be sure to fill in the bubbles completely. If you make a mistake,
just erase the mistake and fill in the correct bubble.
It is best to work on this in a quiet place without taking too many breaks.
If you complete this form at home, you should plan to do it as soon as you get it. If you
complete it before your study visit, please bring the form along to your study visit. If you take
it with you after your study visit, please have it returned within one week (return by
___/____/____). You should use the envelope provided to return your questionnaire.
Page 2
Please answer the next few questions before we ask you about specific foods:
Last week, about how many times each day did
you eat? (including meals & snacks)
O
O
O
O
O
O
O
0
1
2
3
4-5
6-7
8-10
Last week, about how many times did you eat school
lunch or breakfast?
O
O
O
O
O
O
O
0
1
2
3
4-5
6-7
8-10
Last week, about how many times did you eat out,
including fast food or pizza? (Not including school lunch
or breakfast)
O
O
O
O
O
O
O
0
1
2
3
4-5
6-7
8-10
Now you will go through a list of foods. This form is used by people all over the country so there might be foods listed that you never eat.
Don’t worry if you have never heard of some of these foods. Feel free to call ____________________________ if you have any questions
about foods listed or how to fill out this form.
For each of the questions, think about whether or not you ate that food.
Think about all the meals and snacks you had in the last week. These could be foods from anywhere-home, school, vending
machines, the mall, or a restaurant.
You might never eat that food and that is okay. If you did not eat it, fill in the bubble next to “No”.
If you did eat it, think about how often you ate that food over the last week.
o Fill in the bubble under the number of days you ate that food last week.
o Think about the amount of that food you ate each time. Mark the usual amount that you ate when you ate that food last
week. Use the pictures at the end of this booklet to help you estimate the amount of food you ate.
Here is an example of how to fill out the form. If you ate corn chips two days and tortilla chips one day last week and the amount you ate
looked like what is in the picture of the medium bowl, your answer would look like this:
Page 3
First, you will tell us about the breakfast foods you ate last week. Please include times other than breakfast when you eat these foods.
Page 4
Next you will tell us about the fruits that you ate last week.
Page 5
Now you will tell us about meats and other main dishes that you ate last week. Remember to include foods that you ate at home, summer camp, school, work,
vending machines, and restaurants.
Page 6
Page 7
Now you will tell us about soups, breads, and cheeses that you ate last week. Remember to include foods that you ate at home, at summer camp, school, work,
vending machines and restaurants.
Page 8
Now you will tell us about the vegetables that you ate last week. Remember to include foods that you ate at home, summer camp, school, work, from
vending machines, or restaurants.
VEGETABLES
Type of Food
Last week, did you eat any
green salad?
Yes
or
No
How many days last week?
1
2
3‐4
5‐6
If Yes
Day Days
Days
Days
Yes
No
How many
days?
Every
Day
Usual amount eaten in one day?
See picture
Which bowl?
S
M
L
Did you have green beans, or
string beans?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any baked beans,
chili with beans, kidney beans,
pork & beans or any other kind
of beans? (not including refried
beans)
Did you eat refried beans (as a
side dish)?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any corn, corn on
the cob, or chicos?
Yes How many
No days?
See picture
Which plate
How much?
VS
S
M
L
Last week, did you eat any
tomatoes? (Don’t include
tomato sauce)
Yes How many
No days?
How many?
A little
1/2
1
2
Did you eat any greens,
including spinach, mustard
greens, or turnip greens, or
collards?
Did you eat any broccoli?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
Page 9
L
VEGETABLES (Continued)
Type of Food
Did you eat any cauliflower,
cabbage, Brussels sprouts, or
kimchee?
Yes
or
No
How many days last week?
1
Day
If Yes
Yes How many
No days?
2
Days
3‐4
Days
5‐6
Days
Every
Day
Usual amount eaten in one day?
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any coleslaw?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any carrots, either
raw or cooked?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any other
vegetables, like peas, squash,
peppers, or okra?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
When you eat cooked
vegetables, about how often
are these fried vegetables?
Did you eat any sweet
potatoes, or sweet potato pie?
Yes How many
No days?
Seldom or never Sometimes Almost always
See pictures
Which plate?
How much?
VS
S
M
L
Did you eat any French fries,
fried potatoes, Tater Tots, or
hush puppies?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
L
Did you have any other kind of
potatoes, like baked, boiled, or
mashed?
Yes How many
No days?
See pictures
Which plate?
How much?
VS
S
M
Page 10
L
VEGETABLES (Continued)
Type of Food
Did you eat any steamed rice,
brown rice, or Musubi?
Did you eat any fried rice?
Yes
or
No
How many days last week?
1
Day
If Yes
Yes How many
No days?
Yes How many
No days?
2
Days
3‐4
Days
5‐6
Days
Every
Day
Usual amount eaten in one day?
See pictures
Which plate?
How much?
See pictures
Which plate?
How much?
VS
S
M
L
VS
S
M
L
Now you will tell us about the condiments that you used on or with foods that you ate last week.
CONDIMENTS
Yes
or
No
How many days last week?
1
Day
If Yes
2
Days
3‐4
Days
5‐6
Days
Every
Day
Did you eat any gravy, like on
mashed potatoes or on rice?
Yes How many
No days?
Did you have any Ketchup,
salsa, or barbecue sauce?
Yes How many
No days?
Did you use ranch dressing or
other salad dressing, either on
salads or on any other food?
Yes How many
No days?
Do you use any margarine or butter, like on bread, pancakes, on potatoes, or vegetables?
Seldom or never Sometimes Almost always or always
Do you add fatback, bacon, ham hocks, lard, or vegetable oil to your vegetables, beans, or bread?
Seldom or never Sometimes Almost always or always Don’t know
Page 11
Now you will tell us about snacks and sweets that you ate last week. Remember to include foods that you ate at home, summer camp,
school, work, vending machines, and restaurants.
Page 12
Page 13
Now you will tell us about beverages you drank last week. Remember to include foods that you ate at home, summer camp, school,
work, vending machines, and restaurants.
Page 14
BEVERAGES (Continued)
Type of Food
Did you drink any liquid meals
like Slimfast?
Yes
or
No
How many days last week?
1
2
3‐4
5‐6
If Yes
Day Days
Days
Days
Yes How many
No days?
Every
Day
Usual amount eaten in one day?
How many
bottles or cans in
1 day?
1
2
3‐4
5+
Last week, did you drink any
sodas like coke, Sprite, etc.?
(Don’t count diet soda)
Yes How many
No days?
Did you drink diet soda or
unsweetened mineral water?
Yes How many
No days?
Did you drink any Kool‐Aid or
Gatorade?
Yes How many
No days?
Did you drink any Sunny
Delight, Hi‐C, Hawaiian Punch,
or Ocean Spray?
Yes How many
No days?
Did you drink any real orange
juice? (Don’t count orange
sodas)
Did you drink any other real
fruit juices like apple juice or
grape juice? (Remember juice
boxes)
Did you drink any sweet tea or
coffee with sugar?
Yes How many
No days?
Yes How many
No days?
Yes How many
No days?
How many
glasses in 1 day?
1
2
3
4
How many
glasses in 1 day?
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
How many
glasses in 1 day?
How many
glasses or juice
boxes in 1 day?
How many
glasses in 1 day?
How many
glasses in 1 day?
Page 15
How many cups
in 1 day?
We might have missed some of the foods that you often eat. Please write down any other food that you ate 5 or more days last week.
Examples of these foods include Spam Musubi, Chinese dumpling, spring rolls or egg rolls, plate lunch, bento, loco moco, frugal, game like
venision or rabbit, shellfish, red chile con carne, posole, sushi, or anything else that you ate every day or almost every day last week.
1. _______________________________________
5‐6 days
Every day
2. _______________________________________
5‐6 days
Every day
3. _______________________________________
5‐6 days
Every day
Last week did you take any vitamin pills, such as one‐a‐
day, vitamin C, or any other?
Yes
No
Last week, did you take any herbal supplements like
ginseng, echinachea, or any other?
Yes
No
Last week, did you use any protein supplements like
protein powder, creatine, or glutamine?
Yes
No
How often do you eat food that is sold as a special
“low‐fat” food, such as low‐fat chips, low‐fat ice cream,
low‐fat cookies, low‐fat lunch meats, or low‐fat salad
dressing?
Seldom or never
Sometimes
Almost always or always
Don’t know
Yes
Last week, did you eat any cold cereal?
IF YES
Page 16
No
Please write down the name of the cereal you eat most often.
_______________________________________________________
Where did you spend most of your time during the weekdays last week?
In school
On vacation
At camp
Other (specify)
At work
Was what you ate last week fairly typical for you, for what you were doing last week?
Yes
If NO
Would you say you ate:
A lot more
A little more
A little less
A lot less
What made last week different from most other weeks?
Sick
Trying a new diet
Other (specify)
___________________________________________________________________
___________________________________________________________________
No
Is there anything else that you would like us to know about the foods that you eat?
Yes
No
If YES ____________________________________________________________________________________
____________________________________________________________________________________
THANK YOU VERY MUCH FOR FILLING OUT THIS QUESTIONNAIRE!
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| File Type | application/pdf |
| File Title | Microsoft Word - search ffq_5-6-2011 SM |
| Author | stmoxley |
| File Modified | 2012-10-19 |
| File Created | 2011-05-11 |