Form Approved
OMB No. 0920-xxxx
Expiration Date: xx/xx/xxxx
High School Student Dietary Behavior Validation Study
Attachment L2
Dietary Behavior Questionnaire for the Validation Study
How old are you?
12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older
What is your sex?
Female
Male
In what grade are you?
9th grade
10th grade
11th grade
12th grade
Ungraded or other grade
What is your race? (Select one or more responses.)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
The next 3 questions ask about food you ate yesterday. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.
Yesterday, how many times did you eat fruit? Do not count juice.
I did not eat fruit yesterday
1 time
2 times
3 or more times
Yesterday, how many times did you eat vegetables? Include all cooked and uncooked vegetables; salads; and boiled, baked and mashed potatoes. Do not count French fries or chips.
I did not eat vegetables yesterday
1 time
2 times
3 or more times
Yesterday, how many times did you eat beans such as pinto beans, baked beans, kidney beans, refried beans, or pork and beans? Do not count green beans.
I did not eat beans yesterday
1 time
2 times
3 or more times
The next 7 questions ask about food you ate or drank during the past 7 days. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.
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 punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you eat green salad?
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you eat potatoes? (Do not count French fries, fried potatoes, or potato chips.)
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you eat carrots?
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)
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
2 times per day
3 times per day
4 or more times per day
During the past 7 days, how many times did you drink an energy drink, such as Red Bull, Monster, or Rockstar? (Do not count diet energy drinks or sports drinks such as Gatorade or Powerade.)
I did not drink energy 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
2 times per day
3 times per day
4 or more times per day
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Merlo, Caitlin L. (CDC/NCHHSTP/DASH) |
| File Created | 2024:12:22 23:19:06Z |