Real Health Fall 2009: Tell us about your eating habits

Speak Your Mind!

Fitness and nutrition experts agree that keeping track of what we eat daily is a way to control and change our eating patterns. Whether you aspire to lose weight, get fit or simply reap nutritional benefits, becoming aware of your dietary habits is key to achieving these goals. This survey will help you recognize your current relationship with food.
 
1. Name:
 
2. Organization (if you represent one)
 
3. Street address:
 
4. City & state:
 
5. Zip Code:
 
6. Email:
 
7. Phone:
 
8. What year were you born? (e.g., 1975)
 
9. What is your gender?
Female
Male
Transgender
Other
 
10. What is your household income?
Under $15,000
15,000–$34,999
35,000–$49,999
50,000–$74,999
75,000–$99,999
100,000 and over
 
11. What is the highest level of education attained?
Some high school
High school graduate
Some college
Bachelor's degree or higher
 
12. What is your ethnicity?
American Indian or Alaska Native
Arab or Middle Eastern
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Other
 
13. Where do you get Real Health?
I'm a subscriber
My doctor's office
My church
A community or college organization
It was mailed to my home or office
Other: (please specify): 
 
14. Do you have Internet access?
Yes
No
 
15. When are you more inclined to snack? (Check all that apply.)
When I'm studying
When I'm watching TV
When I'm socializing
When I'm bored
When I'm feeling down
Other:  
 
16. What types of foods do you usually eat as snacks?
Fast foods (pizza, french fries)
Ice cream, cake, cookies, candy
Chips or crackers
Nuts and fruits
Other: 
 
17. What kind of beverages do you drink the most? (Check all that apply.)
Soda
Diet soda
Fruit juice
Coffee/tea, sweetened
Water
Coffee/tea, unsweetened
Other: 
 
18. How many alcoholic beverages do you drink during the week? (A glass of wine, bottle of beer, mixed drink or shot glass of liquor counts as one.)
0
1 to 7
8 to 14
15 or more
 
19. How often do you eat dairy products during the week?
Never
1 to 4 times
5 to 8 times
Twice a day or more
 
20. How often do you eat fish or lean meat (chicken, turkey, beef) during the week?
Never
1 to 4 times
5 to 8 times
Twice a day or more
 
21. How often do you eat vegetables (at least ½ cup cooked or raw) during the week?
Never
1 to 4 times
5 to 8 times
Twice a day or more
 
22. How often do you eat fruit (at least ½ cup fresh or frozen) during the week?
Never
1 to 4 times
5 to 8 times
Twice a day or more