Name or ID Number_______________

Please Circle Your Response to the Following Questions.

1. What is your ethnic group?

    White        Latino        African American        Asian/Pacific Islander        Native American        Other

2. Do you smoke cigarettes now?

    No             Yes

IF YES, on the average, about how many cigarettes a day do you smoke now?

    1-5            6-14         15-24            25-34            35 or more

3. About how many times have you gone on a diet to lose weight during the last year?

    Never            1-2                3-5                6-8                9-11                12 or more

4. During the past year have you taken any vitamins or minerals?

    No              Yes

IF NO skip to Question 7.
IF YES complete the following to indicate how often you take the following vitamins and minerals.
 

Multiple Vitamins 

Other Vitamins

5. If you currently take Viatmin E, Vitamin C, or Vitamin D:

    How many units per Vitamin E tablet?

    100                200                400                1000                Don't Know

    How many milligrams per Vitamin C tablet?

    100                250                500                1000                Don't Know

    How many International Units per Vitamin D tablet?

    200                400                600                8000                Don't Know
 

6. Do you regularly take pills containing any of these nutrients? (Circle all that apply.)

    Iron            Beta-Carotene           Zinc            Selenium             No or don't know
 
 
 

7. What kinds of fat do you usually us in cooking (to fry, stir-fry, or saute)? Circle only one or two.

    Don't know or don't cook                 Lard, fatback, baconfat               Pam or no oil

    Crisco                                              Stick margarine                           Butter

    Soft tub margarine                            Oil                                              1/2 Butter, 1/2 margarine

    Low calorie margarine
 

8. What kinds of fat do you usually add to vegetables, potatoes, etc.? Circle only one or two.

    Don't add fat                                    Lard, fatback, baconfat               Whipped butter

    Butter                                              Stick margarine                            Low calorie margarine

    Soft tub margarine                            Oil                                               1/2 Butter, 1/2 margarine

    Crisco
 

9. When you eat the followng foods, how often do you eat a low-fat or non-fat version of that food? Circle your response.

    Cheese                       Always low fat            Sometimes            Seldom/Never

    Yogurt                        Always low fat            Sometimes            Seldom/Never

    Ice Cream                  Always low fat            Sometimes            Seldom/Never

    Cakes/Cookies           Always low fat            Sometimes            Seldom/Never

    Salad Dressing            Always low fat            Sometimes            Seldom/Never
 
 
 

10. Please circle your response to the following questions.

    a. How often do you add salt to your food?
 
                                        Always low fat            Sometimes            Seldom/Never

    b. How often do you eat the skin on chicken?
 
                                        Always low fat            Sometimes            Seldom/Never

    c. How often do you eat the fat on meat?
 
                                       Always low fat            Sometimes            Seldom/Never

    d. How often do you drink beverages that
        contain caffeine  (i.e. coffee, tea, cola)?

                                        Always low fat            Sometimes            Seldom/Never
 

11. This section is about your usual eating habits over thePAST SIX MONTHS.

First:  Check the column to show how often, on average, you ate that food during the past six months.
           Please be careful which column you put your answer in.

Second: Mark whether your usual serving size is small, medium, or large. Please do not omit serving size UNLESS you
              NEVER eat the specified food.

Additional Comments:

• Please do not skip any foods.
• If you never eat a food, mark "Never or less than once a month" and do NOT mark a serving size.
• If you do eat a food,but you eat it less than once per month, mark "Never or less than once a month" AND specify your average serving size.
• A small serving is about one-half the medium serving size shown or less.
• A large serving is about one and a half time the medium serving size shown or more.