Nutrition
  1. How many servings of milk, yogurt or cheese do you eat each day? (1 serving = 1 cup of milk/yogurt or 1½ ounces of cheese)
    None
    1-2
    2-4
    4+
  2. How many servings of beef, fish, poultry or pork do you eat each day? (1 serving = 3 ounces - about the size of a deck of cards)
    None
    1-2
    2-4
    4+
  3. How many servings of fruit or fruit juice do you eat each day? (1 serving = ½ cup)
    None
    1-2
    2-4
    4+
  4. How many servings of vegetable do you eat each day? (1 serving = ½ cup cooked or 1 cup raw)
    None
    1-2
    3-5
    5+
  5. How many servings of rice, pasta, bread, cereal or other grains do you eat each day? (1 serving = ½ cup grains or 1 slice bread or ½ bagel/bun)
    None
    1-3
    3-6
    6-11
    11+
  6. How many cups of water/decaffeinated fluid do you drink each day?
    None
    1-2
    2-4
    4-6
    6+
  7. How many 12 ounce cans of pop do you drink each day?
    0-1
    2-4 cans
    4-6 cans
    6+ cans
  8. When you drink soft drinks, how often do they contain caffeine?
    Always
    Sometimes
    Seldom
    Never
  9. Do you practice a vegetarian diet?
    No, I don't practice a vegetarian diet.
    Yes, I do practice a vegetarian diet and have talked with a health professional about how to eat a healthy vegetarian diet.
    Yes, I do practice a vegetarian diet but haven't had a chance to talk with a health professional about a healthy vegetarian diet.
  10. I frequently:
    Eat three meals each day plus snacks in between meals.
    Skip breakfast, lunch and/or dinner meals.
    Graze throughout the day on whatever is available.
    Have small, frequent meals composed of nutritious choices throughout the day.
  11. How often do you eat breakfast?
    Every day
    Most days
    Occasionally
    Seldom or never
  12. When I want to lose weight, I:
    Find a diet that will help me drop the weight quickly and easily.
    Start skipping meals and snacks.
    Moderate my portion sizes and high fat food choices and increase my exercise.
    Exercise intensely to burn calories.
    I do not want to lose weight.
  13. What is a typical snack choice?
    Chips, candy, sweets and/or pop
    Grain foods like bagels, cracker, pretzels or a cereal bar
    Fresh fruit and vegetables
    Dairy foods like yogurt or cheese
    I don't eat snacks
  14. How often do you eat fast food?
    Never or rarely
    One time per week
    2-4 times per week
    5-10 times per week
    Greater than 10 times per week
  15. Have you ever used diet pills, laxatives or diuretics to lose weight?
    Yes   No
  16. Do you drink coffee or iced tea?
    Yes, every day
    Yes, sometimes
    Never

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