FOODS YOU DRANK OR ATE YESTERDAY | Circle the TIMES YESTERDAY | |||||
BEVERAGES | 0 | 1 | 2 | 3 | 4 | 5 or more |
Water | √ | √ | √ | √ | √ | √ |
Coffee or tea | √ | √ | √ | √ | √ | √ |
Did you add sugar, honey, or flavored creamers to your coffee or tea? | Yes | No | ||||
Did you add artificial sweeteners to your coffee or tea? | Yes | No | ||||
Did you add half and half or whipped cream to your coffee or tea? | Yes | No | ||||
Sugar-sweetened drinks such as soda, iced tea, sports drinks, fruit drink or fruit punch | √ | √ | √ | √ | √ | √ |
Diet soda or artificially-sweetened tea or beverages | √ | √ | √ | √ | √ | √ |
Milk | √ | √ | √ | √ | √ | √ |
Did you use regular or full fat milk or yogurt? | Yes | No | Don’t know | |||
FRUITS AND VEGETABLES | 0 | 1 | 2 | 3 | 4 | 5 or more |
Fruit juice such as orange or apple juice with no added sugar | √ | √ | √ | √ | √ | √ |
Fruit such as apples, bananas, oranges, tangerines, or berries (not juice) | √ | √ | √ | √ | √ | √ |
Green or leafy vegetables such as spinach, kale, broccoli, cabbage, or salad | √ | √ | √ | √ | √ | √ |
Red or orange vegetables such as carrots, tomatoes, peppers, or squash | √ | √ | √ | √ | √ | √ |
BREAD AND GRAINS | 0 | 1 | 2 | 3 | 4 | 5 or more |
Whole grain bread | √ | √ | √ | √ | √ | √ |
Cooked whole grains such as oats, quinoa, brown rice, or whole wheat pasta | √ | √ | √ | √ | √ | √ |
White bread or rolls, wraps, taco shells, tortillas, burritos, or boxed cereal | √ | √ | √ | √ | √ | √ |
Cooked white rice, dumplings, pasta, noodles, grits, baked or boiled potatoes or sweet potatoes but not French fries | √ | √ | √ | √ | √ | √ |
Did you add butter or gravy to bread, rolls, biscuits, or potatoes? | Yes | No | ||||
FOODS YOU ATE OR DRANK LAST WEEK | Circle the TIMES LAST WEEK | |||||
BEVERAGES | 0 | 1 | 2 | 3 | 4 | 5 or more |
Beer, wine, spirits, or wine cooler | √ | √ | √ | √ | √ | √ |
DAIRY | 0 | 1 | 2 | 3 | 4 | 5 or more |
Yogurt | √ | √ | √ | √ | √ | √ |
Cheese | √ | √ | √ | √ | √ | √ |
PROTEIN FOODS | 0 | 1 | 2 | 3 | 4 | 5 or more |
Eggs | √ | √ | √ | √ | √ | √ |
Poultry or chicken that is not fried | √ | √ | √ | √ | √ | √ |
Fish or seafood such as shrimp or clams that is not fried | √ | √ | √ | √ | √ | √ |
Plant proteins such as beans, peas, lentils, chickpeas, hummus, or tofu | √ | √ | √ | √ | √ | √ |
Red meat or pork | √ | √ | √ | √ | √ | √ |
Cold cuts, lunchmeats, hot dogs, or kielbasa | √ | √ | √ | √ | √ | √ |
Bacon, sausage, or pork roll | √ | √ | √ | √ | √ | √ |
Fried foods such as fried chicken, shrimp, fish, eggrolls, rice, or French fries | √ | √ | √ | √ | √ | √ |
Fast food meals; Asian takeout; burgers; wings; nachos; or pizza meals | √ | √ | √ | √ | √ | √ |
Did you add salt to your food at the table? | yes | no | ||||
Did you add olive oil or vegetable oil (not coconut oil) to foods or use it in cooking? | yes | No | Don’t know | |||
SNACKS | 0 | 1 | 2 | 3 | 4 | 5 or more |
Nuts, seeds, or nut butter | √ | √ | √ | √ | √ | √ |
Desserts such as cake, pie, or ice cream | √ | √ | √ | √ | √ | √ |
Snacks such as cookies, brownies, donuts, or candy | √ | √ | √ | √ | √ | √ |
Salty snacks such as potato, corn, or nacho chips, pretzels, crackers, or popcorn | √ | √ | √ | √ | √ | √ |