1. How many meals do you usually eat each day?

    3 meals and 1 snack
    3 meals with no snacks
    2 meals, skipping breakfast or lunch
    I usually eat only 1 meal each day

2. What types of snacks do you eat?

    Fruits, vegetables, nuts, and/or yogurt
    Pretzels, nuts, popcorn, fruit, and/or yogurt
    Chips, pretzels, popcorn, and/or other "junk" food
    Sweets, such as candy, pastries, and/or cookies

3. How many servings of fruits and vegetables do you eat each day?

    Always eat 5 or more servings of fruits and vegetables a day
    Usually eat 3-4 servings
    Usually eat about 1 serving
    I usually eat fruits and vegetables only a few times per week

4. Which dairy products, if any, do you usually eat or drink?

    Fat-free dairy products, such as yogurt and milk
    1 percent milk, 1 percent yogurt, and part-skim cheeses
    2 percent milk, low-fat cream cheese, and low-fat ice cream
    Regular fat dairy products, such as whole milk and ice cream

5. How often do you usually eat fish or shellfish?

    I eat fish or shellfish at least twice a week
    I usually eat fish or shellfish once a week
    I usually eat fish or shellfish a few times a month
    I rarely or never eat fish or shellfish

6. Which types of poultry do you eat?

    Chicken or turkey breast with the skin removed
    Chicken or turkey breast with the skin on
    I occasionally eat breaded, fried chicken or turkey breast
    I frequently choose dark-meat chicken, duck, goose, etc.

7. How often do you eat red meat?

    I never eat red meat
    I eat red meat 1-2 times a month
    Several times a week
    I eat red meat every day

8. Which fats and oils do you use?

    I try to limit my use of any fat or oil when cooking
    I usually use olive or canola oil
    I usually use butter when cooking
    I frequently use bacon fat, fat back, lard, or chicken fat when cooking

9. Apart from coffee, what do you usually drink during the day?

    I usually drink water exclusively
    100 percent fruit juice, water, and diet beverages
    Soda, sports drinks, fruit drinks, and sugar-sweetened iced teas
    Soda and sugar-sweetened beverages

10. When eating out, which of the following would you usually choose?

     Grilled, broiled, baked, or steamed entrées
     Pasta with seafood in marinara or red sauce
     Prime rib, steak, veal, lamb, or pasta in a cream sauce
     Pizza, sausage, hoagies, fried foods, or hot dogs

11. How much exercise do you get?

     I usually exercise for at least 30-60 minutes on most days
     I usually exercise for 30 minutes a few days a week
     I exercise for 30 minutes a few times a month
     I rarely participate in any physical activity

12. How much TV do you watch?

     I rarely watch television
     I watch a few hours of television every week
     I watch less than 2 hours daily
     I usually watch 3 or more hours of television daily

13. How often do you drink alcohol and how much?

     I usually have 1-2 drinks of alcohol a week
     I usually have 1-2 drinks of alcohol daily
     I rarely drink alcohol
     I usually have at least 3 alcoholic drinks daily

14. Do you smoke? If so how many cigarettes do you smoke per day?

     I have never smoked, or I quit more than 8 years ago
     I smoke fewer than 5 cigarettes a day
     I smoke 5-10 cigarettes a day or up to 5 cigars
     I smoke more than 10 cigarettes a day

Source:
Nutrition for Life by Lisa Hark, PhD, RD and Darwin Deen, MD
Published by Dorling Kindersley, New York, 2005.
All Rights Reserved. Permission required to reproduce in any form.