1. Do you suffer from any food allergies or intolerances?
If yes please give details : ........................................................................
Are you taking any vitamin/mineral preparation or other nutritional
supplement ?
If yes please give details: ....
How many meals do you have per day? Four
2. Which type of bread do you usually eat?
White
Brown/Hovis
Granary x
Wholemeal
None
Do you usually buy large or small loaves, sliced or unsliced?
Large x
Small
Sliced x
Unsliced
3. What arrangements do you make for the food you eat at lunchtime?
Bring lunch from home x
Buy food from retail outlet
Eat in canteen
Don't eat lunch
4. What arrangements do you make for the food you eat in the evening?
times / wk
Cook at home x 7
At home
- Supermarket ready meals
Eat out - Restaurant
Takeaway Food
5. What kind of milk do you usually use?
Full cream milk
Semi-skimmed milk x
Skimmed milk
Soya
None
How much milk do you drink daily i.e. in tea/coffee/milkshakes etc.
> 1 pint (state) x
1 pint (600ml)
½ pint (300ml)
¼ pint (150ml)
None
7. What kind of spreading fat do you use?
Butter
Margarine x
Low fat spread
Don't use any
Please state which type/brand ......Flora Buttery...................................
Do you spread it ......?
Thickly
Thinly x
8. What type of fat do you use for cooking?
Oil x
Butter
Margarine
Lard
Don't use any
Please state which type/brand ...Berio Olive Oil......................................
9. How often do you eat food that is fried?Daily
1-3 times/week
4-6 times/week
Less than once/week x
10. What do you do with the visible fat on your meat?
Eat most of the fat
Eat as little as possible x
Eat some of the fat
Don't eat meat6
11. How many cups of tea/coffee do you drink per day? 2 or 3.
12. What do you add to tea/coffee?
MILK x
SUGAR
SWEETENER
NOTHING
How many tablespoons of milk do you take in tea and coffee?
_____ tablespoons milk in a cup of tea
__2___ tablespoons milk in coffee13. Do you drink alcoholic drinks?
YES X NO
If YES, how many units you drink in a typical week?
1 unit = ½ pint beer/lager
1 glass wine,
1 measure spirit.
__4___ units per week