Beruflich Dokumente
Kultur Dokumente
MARKING INSTRUCTIONS
2. Are you:
Less than 9
9
10
11
15
12
16
13
17
14
18 or older
3. Your
Male
Female
4. Your
Height
Weight
(lbs)
2
3
I
N
F
T
No
3/8 spine
perf
12
35
69
10 or more
OW
CK
6. Do you take any other separate vitamin or mineral pills? (NOT the multivitamin pill listed in question 5b)
Yes
No
Iron
Vitamin D
Vitamin C
Fish Oil
Other
please specify:
7
8
These questions ask about what you ate and drank over the past year.
DRINKS
3. What is the usual serving
SERIAL #
page ONE
1
2
3
4
Powerade or Gatorade)
or sugar-sweetened
vitamin water
(individual bottle)
9. Milkshake (1)
Never/less than
1 per month
13 per month
1 per week
More than 1 per week
herbal) (1 cup)
7. Regular energy
drinksRed Bull, Rock Star
(individual can/bottle)
Never/less than 1 per month
13 bottles per month
1 bottle per week
24 bottles per week
56 bottles per week
1 bottle per day
2 bottles per day
3 or more bottles per day
11. Decaffeinated
coffee (1 cup)
13. Coffee drinks with nonfat 14. Coffee drinks with low-fat 15. Iced coffee with nonfat
milk, e.g., Cappuccino,
Mocha, Latte
bottle or can)
(1 glass)
page TWO
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
3/8 spine
perf
DAIRY FOODS
1. What type of white milk
drink (1 packet,
serving/can)
Never/less than 1 per month
13 times per month
Once per week
24 times per week
More than 4 times per week
3/8 spine
perf
Skim/nonfat milk
1% milk
2% milk
Whole milk
Soy milk
Dont know
Dont drink milk
3. Chocolate or other
cereal)
(1 serving or can)
3
4
5
1
6
2
7
8
9
10
11
Nonfat
Lowfat
Regular
Dont know
not butter
13
SERIAL #
page THREE
12
14
Vegetable oil
Safflower oil
Dont know
15
F
16
MAIN DISHES
1. Cheeseburger (1)
Never/less than 1 per month
13 per month
One per week
24 per week
More than 4 per week
5. Pizza (2 slices)
6. Tacos (1)
7. Burritos (1)
chicken or turkey, do
you eat the skin?
or fish sandwich
(1 serving)
Yes
No
Sometimes
Dont eat chicken or turkey
page FOUR
1
2
3
4
5
6
7
8
3/8 spine
perf
4. Veggieburger (1)
2. Hamburger or
9
10
11
12
13
14
15
16
3/8 spine
perf
(1 serving)
24. Lasagna/baked
no sauce (1 serving)
ziti/ravioli (1 serving)
25. Macaroni and cheese or 26. Spaghetti or other pasta 27. Eggse.g., scrambled,
other pasta with cream
sauce (1 serving)
(1 serving)
fried, in breakfast
sandwich (1)
Never/less than 1 per month
13 eggs per month
One egg per week
24 eggs per week
More than 4 eggs per week
17
18
19
20
21
22
23
24
25
26
27
28
29
30
SANDWICHES
1. Peanut butter sandwich (1)
2. Chicken or turkey
sandwich (1)
3. Roast beef
sandwich (1)
2
3
4
SERIAL #
page FIVE
OTHER FOODS
1. Ketchup
Never/less than 1 per month
13 times per month
Once per week
24 times per week
More than 4 times per week
or chowder (1 bowl)
Never/less than 1 per month
13 bowls per month
1 bowl per week
26 bowls per week
1 or more bowls per day
7. Salsa (1 serving)
Never/less than 1 per month
13 times per month
Once per week
26 times per week
1 or more times per day
4. Mayonnaise (1 Tbs.)
(1 bowl)
Cheerios
Honey Nut Cheerios
Frosted Mini-Wheats
Frosted Flakes
Cinnamon Toast Crunch
Other:
9. Croissant (1)
(1 square)
Never/less than 1 per month
13 per month
1 per week
24 per week
More than 4 per week
page SIX
5
6
7
8
RK
HB
LC
FL
PB
SK
CC
3/8 spine
perf
3
4
1
28
3
4
5
6
7
8
9
10
3/8 spine
perf
5. Applesauce (1 serving)
Never/less than 1 per month
13 per month
1 per week
26 per week
1 or more per day
9. Oranges (1)
Never/less than 1 per month
13 per month
1 per week
26 per week
1 or more per day
browns (1 serving)
mashed (1 serving)
13
14
15
17
2. Grapes (bunch)
3. Bananas (1)
6. Pears (1)
7. Cantaloupe, melon
(1 wedge)
Never/less than once per month
13 times per month
Once per week
More than once per week
14. Pineapple
11
12
16
(1 serving)
(1 glass)
page SEVEN
4. Apples (1)
Never/less than 1 per month
13 per month
1 per week
26 per week
1 or more per day
8. Watermelon
(1 wedge)
Never/less than once per month
13 times per month
Once per week
More than once per week
1
2
3
4
5
6
14
7
8
9
1
10
2
3
11
12
13
14
15
16
19. V8 Fusion
(1 small glass)
(1 small glass)
29. Green/red/yellow
peppers (3 slices)
(small serving)
eggplant (1 serving)
Never/less than 1 per month
13 times per month
Once per week
24 times per week
More than 4 times per week
(small serving)
(1 serving)
(1 serving)
Never/less than 1 per month
13 times per month
Once per week
24 times per week
More than 4 times per week
SERIAL #
page EIGHT
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
3/8 spine
perf
41
SNACK FOODS/DESSERTS
2. Corn chips/Doritos (1 small bag) 3. Popcorn (1 small bag)
3/8 spine
perf
(2 squares)
Dings/Swiss Rolls/Twinkies
(1 package)
Never/less than 1 per month
13 per month
Once per week
26 per week
1 or more per day
9. Graham crackers
page NINE
(1 pack)
Never/less than 1 per month
13 packs per month
14 packs per week
More than 4 packs per week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
sugar free
or M & Ms (1 bar or
packet)
Never/less than 1 per month
13 per month
1 per week
26 per week
1 or more per day
fudgesicle (1)
Never/less than 1 per month
13 per month
1 per week
24 per week
More than 4 per week
18
19
20
21
22
23
24
25
26
27
28
29
or honey (Tbs.)
30
31
SERIAL #
page TEN
17
3/8 spine
perf
(1 serving)
page ELEVEN
3/8 spine
perf
3/8 spine
perf
S C A N T R O N
EliteView EM-290520-2:654321
SERIAL #
page TWELVE