NUTRITION ASSESSMENTS:

EATING HABITS QUESTIONNAIRE

Contact person:
Carol Olander
Office of Analysis and Evaluation
US Dept. Of Agriculture
(703) 305 2134

Instructions:

• This is not a test. There are no right or wrong answers.
• Read or listen to each question carefully and think about it before you choose an answer.
• To choose an answer, put an X next to your choice.
• Choose only one answer for each question unless you are asked to choose more than one.
• It is OK to check "don't know" if you really don't know the answer.
• If you want to change an answer, erase your old answer and mark your new choice. Be sure to erase completely.
• Do not skip any questions.

Are you a boy or a girl?

___Boy ___Girl

Check the food in each line that you think is better for your health.

1. ___cookies OR ___an apple

2. ___buttered popcorn OR ___unbuttered popcorn

3. ___chocolate cake OR ___an orange

4. ___ice cream OR ___fresh fruit popsicle

5. ___whole milk OR ___low-fat or skim milk

6. ___frozen yogurt OR ___ice cream

7. ___french toast OR ___whole wheat toast

8. ___grilled chicken sandwich OR ___hamburger

9. ___baked potato OR ___french fries

10. ___fruit juice OR ___soda

11. ___donut OR ___bread

12. ___cold or ready-to-eat cereal OR ___eggs and bacon

13. ___whole milk OR ___low-fat or skim milk

14. ___frozen yogurt OR ___ice cream

15. ___green salad OR ___french fries

16. ___raisins OR ___candy bar

17. ___french fries OR ___baked potatoes

18. ___donuts OR ___toast

19. Joe ate cereal with milk and a banana and drank orange juice for breakfast. How many different food groups did Joe eat from the Pyramid? Mark only one answer.

___1
___2
___3
___4
___Don't Know

20. What is a "balanced diet"? Mark only one answer.

___Eating a lot of fruits and vegetables
___Eating the same food every day
___Eating only the foods pictured in the Pyramid
___Eating different foods from all the food groups
___Don't know

21. Which of the following is one serving size from the grain group?

___2 slices of bread
___1 cup of spaghetti or other noodles
___2 cups of ready to eat cereal
___a banana
___Don't know

22. If you want to eat more fruit, which of the following would you choose?

___Orange soda
___grape jelly
___Strawberry ice cream
___A banana
___Don't know

23. From which food group in the Pyramid should you eat the most servings a day? Mark only one answer.

___Bread, cereal, rice, and pasta
___Meat, poultry, fish, eggs, dry beans, and nuts
___Vegetables
___Fruit
___Don't know

The following questions ask you about Nutrition Facts food labels.

Here is an example of a Nutrition Facts food label:

Nutrition facts
Serving Size: 6 chips
Servings Per Container: 2
Amount per serving
Calories 120 Calories from fat 30%

% daily value
Total fat 4 g 6%
Saturated fat 1 g 5%
Cholesterol 0 mg 0%
Sodium 210 mg 9%
Total Carbohydrate 7 g 3%
Dietary Fiber 0 mg 0%
Sugar 0 g 0%
Protein 4 g

Circle the letter that best describes your opinion of the following statements.

24. Reading the nutrition facts food labels makes it easier to choose healthier foods.

A - I strongly agree
B - I agree
C - I disagree
D - I strongly disagree

25. When I use Nutrition Facts food Labels, I make healthier food choices.

A - I strongly agree
B - I agree
C - I disagree
D - I strongly disagree

26. I use the Nutrition Fact labels to help me choose what to buy or eat.

___always
___often
___sometimes
___almost never
___never

Use these Nutrition Facts labels to help you answer the next group of questions.

Nacho Munchies Nutrition facts: Serving Size: 6 chips Servings Per Container: 2 Amount per serving Calories 120 Calories from fat 30% % daily value Total fat 4 g 6% Saturated fat 1 g 5% Cholesterol 0 mg 0% Sodium 210 mg 9% Total Carbohydrate 7 g 3% Dietary Fiber 0 mg 0% Sugar 0 g 0% Protein 4 g

Cheese Chips Nutrition facts: Serving Size: 6 chips Servings Per Container: 2 Amount per serving Calories 160 Calories from fat 62% % daily value Total fat 11 g 18% Saturated fat 1 g 5% Cholesterol 0 mg 0% Sodium 320 mg 14% Total Carbohydrate 15 g 5% Dietary Fiber 0 mg 0% Sugar 0 g 0% Protein 2 g

27. Which chips would you choose if you were trying to lower the amount of total fat in your diet?

___Cheese chips
___Nacho Munchies
___Can't tell from label
___Don't Know

28. If you ate 12 Nacho Munchies chips, how much total fat would you have eaten?

___4 grams
___8 grams
___24 grams
___Don't know

Check the box under YES or NO to answer the following questions:

In the last 2 weeks, did you ever. . .	YES	NO
29. Eat fruits ate home for breakfast?
30. Eat fruits or vegetables at home for snacks?
31. Go shopping with someone in your family and help choose fruits or vegetables?
32. Eat fruits or vegetables at home that you had never tried before?
33. Eat a new grain, such as brown rice, bulgur or pita bread, that you had never tried before?

Check the box under YES, NO, or Didn't Have to Ask for each of the following questions.

In the last 2 weeks, did you ever. . .	YES	NO	Didn't have to ask
34. Ask someone in your family to buy fruits or vegetables?
35. Ask someone in your family to buy more grains, such as bread, cereal, spaghetti or other noodles?
36. Ask someone in your family to buy snacks that were low in fat, such as pretzels, low-fat yogurt or low-fat cookies?

Check the box under Yes, No, or Didn't Go Out to Eat for the following question:

In the last 2 weeks, did you ever. . .	YES	NO	Didn't go out to eat
37. Eat fruits or vegetables when you went out to eat, not including the foods you ate at school?

38. Think about all of the foods you ate yesterday. Which of the following food groups did the foods you ate yesterday come from? Put a check next to all of the food groups that apply.

___Bread, cereal, rice, and pasta group
___Milk, yogurt, and cheese group
___Vegetable group
___Meat, poultry, fish, dry beans, eggs, and nuts group
___Fruit group
___Don't know

Mark the number below that best describes your opinion of the school lunch program. The numbers mean:

1 - I strongly agree
2 - I agree
3 - I disagree
4 - I strongly disagree

39. It offers food that I like.	1	2	3	4
40. It offers food that is good for my health.	1	2	3	4
41. It offers new foods to try.	1	2	3	4
42. It offers foods that taste good.	1	2	3	4
43. It offers a variety of foods that I will eat.	1	2	3	4
44. It offers fruits that I will eat.	1	2	3	4
45. It offers vegetables that I will eat.	1	2	3	4

Mark the number below that best describes you. The numbers mean:

1 - I strongly agree
2 - I agree
3 - I disagree
4 - I strongly disagreee

46. I like to taste new foods.	1	2	3	4
47. It is bad for me to eat bread, cereal, and other grains many times per day.	1	2	3	4
48. I like having fruits around for snacks.	1	2	3	4
49. Trying new foods is good for me.	1	2	3	4
50. I like to ask someone in my family to buy more fruits and vegetables.	1	2	3	4
51. I don't like the taste of foods that are good for me.	1	2	3	4
52. I like to choose snacks lower in fat.	1	2	3	4

Please use the number ratings below to show how much you agree with the following statements:

1 - I strongly agree
2 - I agree
3 - I disagree
4 - I strongly disagree

If I eat fruits, vegetables and grains, such as breads, cereals, spaghetti, and other noodles every day. . .

53. My friends will make fun of me.	1	2	3	4
54. My family will be proud of me.	1	2	3	4
55. I will have a nicer smile.	1	2	3	4
56. My friends will not come to my house to eat.	1	2	3	4
57. My friends will start eating them too.	1	2	3	4
58. I will be healthier than I am now.	1	2	3	4
59. I will have less energy.	1	2	3	4
60. I will become stronger.	1	2	3	4
61. I will think better in class.	1	2	3	4
62. I won't enjoy eating as much as before.	1	2	3	4

The following questions ask about people you know who may change your eating. Please check the box under YES, NO or Don't Know:

63. Who eats lot of fruits?

	YES	NO	Don't Know
a) Your parents or guardians
b) Your brothers and sisters
c) Your teachers
d) Your friends

66. Who eats lots of grains, such as cereal, rice, spaghetti and other noodles?

	YES	NO	Don't Know
a) Your parents or guardians
b) Your brothers and sisters
c) Your teachers
d) Your friends

63. Who tries new foods?

	YES	NO	Don't Know
a) Your parents or guardians
b) Your brothers and sisters
c) Your teachers
d) Your friends

64. If you are going to eat healthier food, then would you ever choose to:

	YES	NO	MAYBE
a) Eat a popsicle instead of ice cream?
b) Eat fresh fruit instead of a candy bar?
c) Eat cereal instead of a donut for breakfast?
d) Try new foods?
e) Order new food in a restaurant?
f) Eat more servings of fruits or vegetables than you eat right now
g) Eat six or more servings of grains, such as cereals, rice, spaghetti, and other noodles each day?
h) Use Nutrition Facts labels to choose low-fat foods?

Please use the number ratings below to show how much you agree with the following statements:

1 - I strongly agree
2 - I agree
3 - I disagree
4 - I strongly disagree

65. Foods such as ice cream, chips and cookies are okay to eat, but not all the time.	1	2	3	4
66. Snacks such as fruit, pretzels, lowfat yogurt or low-fat cookies can be an important part of a healthy diet.	1	2	3	4
67. It's okay to eat anything you want, whenever you want.	1	2	3	4

Mark YES or NO for each of the following questions:

68. In the last month, have you done nutrition activities in your school cafeteria, such as taste-testing new foods?

___YES ___NO

69. In the last month, have you done nutrition activities in your community, such as a nutrition fair or a fruit and vegetable taste-test?

___YES ___NO

70. In the last month, have you talked about good nutrition with your family?

___YES ___NO

71. In the last month, have you worked with your family on any nutrition homework?

___YES ___NO

72. Have you seen the Disney characters, Pumba or Timon, talk about good nutrition on TV?

___Yes, at least once
___Yes, many times
___No, never

73. Mark the box that best describes your opinion of the following vegetables:

	I have never tasted this	I don't like this	I like this a little	I like this a lot
a) Carrots
b) Celery
c) Greens (collard, turnip, mustard, etc.)
d) Potatoes, baked
e) Corn
f) Peas (green, sweet or english)
g) Tomatoes
h) Broccoli
i) Lettuce
j) Beans (green, string, or snap)
k) Radishes
l) Cauliflower
m) Cucumber
n) Spinach
o) Bean sprouts
p) Peppers (red, green, or yellow)
q) Mushrooms
r) Squash (zucchini, yellow, butternut)

74. Mark the box that best describes your opinion of the following fruits:

	I have never tasted this	I don't like this	I like this a little	I like this a lot
a) Peaches
b) Apple juice
c) Bananas
d) Apples
e) Cantaloupe
f) Grapes
g) Orange juice
h) Oranges
i) Fruit salad
j) Applesauce
k) Blueberries
l) Apricots
m) Kiwi
n) Pears
o) Plums
p) Mango
q) Pineapple
r) Honeydew melon

75. Mark the box that best describes your opinion of the following foods:

	I have never tasted this	I don't like this	I like this a little	I like this a lot
a) Bagels
b) Spaghetti and other noodles
c) Couscous
d) Rice
e) Cold or ready-to-eat cereal
f) Hot cereal (oatmeal, cream of wheat)
g) Rice cakes
h) Rolls
i) Grits
j) English muffins
k) Tortillas
l) Unbuttered popcorn
m) Pretzels
n) Bread or toast
o) Granola
p) Corn bread
q) Pita bread
r) Low-fat cookies

Evaluation Tools Page

ENTRY DATE:: January 1999