Nutrition Questionnaire

 

There are many reasons why we choose the foods that we eat.  Looking at this list, which would you say has the greatest influence on your choice of foods?  Which has the second greatest influence?  Which has the third greatest influence?  Please write down the corresponding number in the appropriate blank.

 

1. Quality or freshness of food                                                                

2. Habit or routine                                        

3. Price of food                                                                          

4. What my family or spouse/partner will eat               

5. Trying to eat a healthy or balanced diet                                       

6. Taste of food                                                                          

7. Convenience in preparation                                                   Greatest influence: ______________

8. Presentation or packaging                                                      2nd Greatest Influence: ___________

9. Slimming                                                                                    3rd Greatest Influence: ___________  

10. Vegetarian or other special eating habits                        

11. Prescribed diet                                                              

12. Content of additives or colors or preservatives             

13. Cultural or religious or ethnic background                   

14. Availability of food                                                        

15. Someone else decides on most of the food I eat             

16. Other (please specify _________________)

 

 

There is no one definition for healthy eating.  Can you please describe to me how you personally would describe healthy eating?  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

 

 

 

 

There are a number of sources of information on healthy eating, some of which you may trust more than others.   Please tell me how much you personally would trust or distrust information coming from the following sources, using the five-point scale below.

 

   1 = Distrust totally

                                                                2 = Tend to distrust

                                                                3 = Tend not to trust nor distrust

                                                                4 = Tend to trust

                                                                5 = Trust fully

 

___ 1. Department of Health

___ 2. Advertising

___ 3. Health professional (such as a doctor, nurse, nutritionist, pharmacist)

___ 4. Articles in newspapers or magazines

___ 5. Program on television or radio

___ 6. Information on food packaging

 

 

Turning to specific foods, would you say that people in general should eat MORE, LESS, or the SAME AMOUNT than they usually eat of the following foods to eat healthier?  Please use the following three-point scale.

 

1 = Less

 2 = Same

 3 = More

 

___ 1. Oily fish (for example, trout, mackerel, or salmon)

___ 2. Savory snacks (for example, peanuts or granola bars)

___ 3. Fruit and vegetables

___ 4. Sugar and sweets

___ 5. Bread and potatoes

___ 6. Butter or margarine

___ 7. Meat (for example, beef, chicken, or pork)

 

 

 

 

 

 

Please tell me to what extent you agree or disagree with each of the following statements.  Use the five-point scale below.

 

1 = Disagree strongly

2 = Tend to disagree

3 = Tend not to agree nor disagree

4 = Tend to agree

5 = Agree strongly

 

___ 1. I do not need to make any changes to the food that I eat, as it is already healthy enough.

___ 2. I usually do not think about the nutritional aspects of the types of food that I eat

___ 3. I frequently look for information on healthy eating.

___ 4. I try to eat healthy food whenever possible.

 

 

Have you ever changed your eating habits to try to eat healthier?  Please check one.

___ Yes

___ No

 

Are you eating or trying to eat healthier these days?  Please check one.

___ Yes

___ No

 

How long have you been eating or trying to eat healthier?  Please check one.

___ Less than 6 months

___ 6 months or more

___ I am not trying to eat healthier

 

In the past month, have you thought about changes you could make to eat healthier?  Please check one.

 

___ Yes

___ No

 

 

How confident are you that you will make some changes in order to eat healthier during the next month?  Please check one.

 

___ Not at all confident

___ Slightly confident

___ Confident

___ Quite confident

___ Very confident

 

Please read the following list of eating habits.  Determine their importance to you personally, using the five-point scale below.

 

1 = Very unimportant

2 = Somewhat unimportant

3 = Neither important nor unimportant

4 = Somewhat important

5 = Very important

 

___ 1. Eat less sugary foods

___ 2. Avoid foods with additives or colors or preservatives

___ 3. Eat less fatty foods

___ 4. Drink less alcohol

___ 5. Eat a smaller amount of food

___ 6. Eat less processed foods

___ 7. Avoid missing meals

___ 8. Eat more fruits or vegetables

___ 9. Eat more wholemeal or wholegrain foods

___ 10. Drink more water

___ 11. Eat a wider variety of foods

___ 12. Choose light or low-fat or low-calorie foods

___ 13. Eat less meat

___ 14. Drink less coffee or tea

___ 15. Eat more cheese or milk or yogurt

___ 16. Eat less in between meals

1 = Very unimportant

2 = Somewhat unimportant

3 = Neither important nor unimportant

4 = Somewhat important

5 = Very important

 

___ 17. Eat more starch-rich foods

___ 18. Eat less salt

___ 19. Eat less bread or potatoes or pasta

___ 20. Other (please specify ________________________________)

 

 

Some people believe that healthy eating has specific benefits, some of which are listed below.  Which ONE benefit would be the most personally significant for you?  Please mark an “X” next to the appropriate line.

 

___ 1. Control my weight

___ 2. Look attractive

___ 3. Prevent disease in general (for example, heart disease, cancer, etc.)

___ 4. Be physically fit

___ 5. Live longer

___ 6. Do well at sport

___ 7. Have plenty of energy

___ 8. Have a better quality of life

___ 9. Stay healthy

___ 10. Other (please specify ________________________________)

 

 

 

 

 

 

 

 

 

Below is a list of difficulties that people may experience in trying to eat healthier.  Looking at this list, which would you say would be the greatest difficulty in order for you to eat healthier?  Which would be the second difficulty?  Which would be the third difficulty?  Please write down the corresponding number in the appropriate blank.

 

1. Irregular work hours

2. Unappealing food

3. Cooking skills

4. Busy lifestyle

5. Feeling conspicuous amongst others

6. Limited choice when I eat out

7. Taste preferences of family or friends

8. Too great a change from my current diet

9. Healthy options not available in store or home

10. Giving up foods that I like                                                 Greatest difficulty: ________

11. Strange or unusual foods                                                                2nd Greatest difficulty: _____

12. Price of healthy foods                                                                3rd Greatest difficulty: _____

13. Healthy foods more awkward to carry home from store

14. Healthy food is more perishable

15. Not knowing enough about healthy eating

16. Not enough food to satisfy hunger

17. Lengthy preparation

18. “Experts” keep changing their minds

19. Willpower

20. Storage facilities

21. Limited cooking facilities

22. Other (please specify ______________________)

 

 

 

 

 

 

 

Please choose one statement that best describes your attitudes about eating and drinking from the following list.  Mark an “X” next to the statement you choose.

 

___ 1. I only eat and drink things that are good for me.

___ 2. I don’t worry too much as long as I eat enough healthy things such as fruit and vegetables.

___ 3. I can eat and drink anything as I take plenty of exercise.

___ 4. I eat and drink the things I enjoy and don’t worry about it.

___ 5. I am not interested in food and will eat anything.