12.

Which of these foods did you eat yesterday?

 

(circle all that apply):

Cheese

Pizza

Macaroni and cheese

Yogurt

Cereal with milk

Other foods made with cheese (such as tacos, enchiladas, lasagna, cheeseburgers)

Corn

Potatoes

Sweet potatoes

Green salad

Carrots

Collard greens

Spinach

Turnip greens

Broccoli

Green beans

Green peas

Other vegetables

Apples

Bananas

Berries

Grapefruit

Melon

Oranges

Peaches

Other fruit

Meat

Fish

Chicken

Eggs

Peanut butter

Nuts

Seeds

Dried beans

Cold cuts

Hot dog

Bacon

Sausage

Cake

Cookies

Doughnut

Pastry

Chips

French fries

Other deep-fried foods, such as fried chicken or egg rolls

Bread

Rolls

Rice

Cereal

Noodles

Spaghetti

Tortillas

Were any of these whole grain?

No

Yes

13.

Is the way you ate yesterday the way you usually eat?

No

Yes

Life-Style

14.

Do you exercise for at least 30 minutes on a regular basis (3 times a week or more)?

No

Yes

15.

Do you ever smoke cigarettes or use smokeless tobacco?

No

Yes

16.

Do you ever drink beer, wine, liquor, or any other alcoholic beverages?

No

Yes

17.

Which of these do you take?

 

(circle all that apply):

 

Prescribed drugs or medications

 

Any over-the-counter products (such as aspirin, Tylenol®, antacids, or vitamins)

 

Street drugs (such as marijuana, speed, downers, crack, or heroin)



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