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Mec Phase Iii Main Questionnaire – Personal Information

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Mec Phase Iii Main Questionnaire – Personal Information SPHS-MEC3 & Diet Screener Form Language: English/Mandarin MAIN QUESTIONNAIRE SINGAPORE POPULATION HEALTH STUDIES – MEC PHASE III MAIN QUESTIONNAIRE – PERSONAL INFORMATION Name: (Mr / Ms / Mrs)* _________________________________________________________________ Gender: 1) Male 2) Female NRIC: D.O.B D D M M Y Y Y Y Ethnicity: 1) Chinese 2) Malay 3) Indian 4) Others, please specify: ________________ Preferred Language: 1. _____________________________ 2. _______________________________ Mailing Address Residential Address □ Same as residential address Block Street / Building Name Unit No # - # - Postal Code Home No Mobile No Office No Contact 1 Contact 2 Contact 3 (Relative’s mobile): __________________________ Relation: ____________________ As an additional option and source of contact to facilitate follow-up Email Address: INTERVIEW DETAILS STUDY ID Interviewer’s Name Interview Language Interview Date / / Interview Time AM / PM* Page 1 of 63 Annex I, IRB V3, 8 March 2019_MECIII SPHS-MEC3 & Diet Screener Form Language: English/Mandarin MAIN QUESTIONNAIRE Interviewed by: Document the full name of the interviewer. Name: [*Mr/Ms/Mrs] Circle the appropriate salutation. Document the name as it is printed on the participant’s NRIC. Gender: * M / F Document the gender as printed on the NRIC Ethnicity Document as per NRIC. Specify Other, e.g. Bugis, Sikh, Pakistani D.O.B: Document the date of birth as printed on the NRIC. Residential Address: Document the main address that the participant is currently staying at. Mailing Address [fill in only if different from Document mailing address only if different from the above]: residential address. Contact No. Obtain telephone number where applicable/contactable. If no contact number is available, document 77777777. Preferred Language: 1.___ 2.____ Document the language(s) that is spoken according to the order of preference 1. Date and time of interview commences: Document the date and time the interview was conducted. Note to Interviewer: Each correction of entry must be signed and dated. Do not interpret or make assumptions while interviewing; document participant’s response accordingly. All are single answer questions. Circle the appropriate answer number. Do not leave any blanks unless instructed. Enter all date fields in the format “DDMMYYYY”. For other fields: Day, Month or String/Text Numeric Year Where not applicable, enter: 77 / 7777 NNN 777 Where Participant refuses to answer, enter: 88 / 8888 RRR 888 Where Participant does not know, enter: 99 / 9999 DDD 999 Page 2 of 63 Annex I, IRB V3, 8 March 2019_MECIII SPHS - MEC3 ONLINE NUTRITION SURVEY Annex H IRB v1, dated 28 Nov 2018 Page Questions Answer options Number Instructions Thank you for agreeing to take part in this survey about the foods you usually eat. 1. Please recall your usual intake over the past year. 1 2. There are no right or wrong answers; please respond as honestly as possible. 3. Some of the questions allow you to give multiple answers. This will always be indicated in the question. If you would like to watch a short tutorial about this questionnaire, please click on 2 the link below. If you would like to skip the tutorial and go straight to the survey, please click 'Next'. BREAD White bread (including naan) Wholemeal bread Which of the following items do you 3 Bread with dried fruit/nuts/seeds e.g. walnut bread, raisin consume at least once a month? bread, corn bread, multigrain None of these (You can choose more than one) How often do you consume 2 slices of: 4 Daily Weekly Monthly White bread (including naan) 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 2 slices of: 5 Daily Weekly Monthly Wholemeal bread 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 2 slices of: 6 Bread with dried fruit/nuts/seeds Daily Weekly Monthly e.g. walnut bread, raisin bread, corn 4+ times 4 - 6 times 2 - 3 times bread, multigrain 2 - 3 times 2 - 3 times 1 time 1 time 1 time SPHS - MEC3 ONLINE NUTRITION SURVEY Page Questions Answer options Number BREAD SPREADS Margarine e.g. olive spread, Planta® Butter Kaya Which of the following items do you 7 Peanut butter consume at least once a month? 1 Jam/Marmalade/Honey Chocolate spread e.g. Nutella® None of these (You can choose more than one) How often do you consume 1 teaspoon of: 8 Daily Weekly Monthly Margarine 4+ times 4 - 6 times 2 - 3 times e.g. olive spread, Planta® 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 teaspoon of: 9 Daily Weekly Monthly Butter 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 teaspoon of: 10 Daily Weekly Monthly Kaya 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 teaspoon of: 11 Daily Weekly Monthly Peanut butter 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 teaspoon of: 12 Daily Weekly Monthly Jam/Marmalade/Honey 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 teaspoon of: 13 Daily Weekly Monthly Chocolate spread 4+ times 4 - 6 times 2 - 3 times e.g. Nutella® 2 - 3 times 2 - 3 times 1 time 1 time 1 time SPHS - MEC3 ONLINE NUTRITION SURVEY Page Questions Answer options Number OTHER BREADS French toast Pizza Thosai, plain or with filling e.g. potato Roti prata, plain or with egg/cheese (including paratha) 1 Chapati Which of the following items do you Murtabak 14 consume at least once a month? Puri (deep-fried Indian bread) Sweet filled buns (including pau) e.g. red bean, coconut, custard Savoury filled buns (including pau) e.g. chicken, char siew, cheese, hot dog None of these (You can choose more than one) How often do you consume 2 triangular slices of: 15 Daily Weekly Monthly French toast 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 slice (from 14” pizza) OR 2 slices (from 9" pizza) of: 16 Daily Weekly Monthly Pizza 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 piece of: 17 Daily Weekly Monthly Thosai, plain or with filling 4+ times 4 - 6 times 2 - 3 times e.g. potato 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 piece of: 18 Daily Weekly Monthly Roti prata, plain or with egg/cheese 4+ times 4 - 6 times 2 - 3 times (including paratha) 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 piece of: 19 Daily Weekly Monthly Chapati 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time SPHS - MEC3 ONLINE NUTRITION SURVEY Page Questions Answer options Number How often do you consume 1/4 of a whole OR 2 small pieces of: 20 Daily Weekly Monthly Murtabak 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 1 time 1 time How often do you consume 1 piece of: 21 Daily Weekly Monthly Puri (deep-fried Indian bread) 4+ times 4 - 6 times 2 - 3 times 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 piece of: 22 Daily Weekly Monthly Sweet filled buns (including pau) 4+ times 4 - 6 times 2 - 3 times e.g. red bean, coconut, custard 2 - 3 times 2 - 3 times 1 time 1 time 1 time How often do you consume 1 piece of: 23 Daily Weekly Monthly Savoury filled buns (including pau) 4+ times 4 - 6 times 2 - 3 times e.g. chicken, char siew, cheese, hot dog 2 - 3 times 2 - 3 times 1 time 1 time 1 time RICE Rice, plain, boiled/steamed (excluding porridge) Flavoured rice porridge e.g. chicken, pork, duck, fish, vegetarian Plain rice porridge Fried rice Flavoured rice e.g. chicken rice, briyani, nasi lemak, pilau, nasi minyak, yellow rice, olive rice, tomato rice, saffron rice, Which of the following items do you 24 yam rice consume at least once a month? Flavoured rice dish (mixed with meat/veg) e.g. bi bi bap, claypot, mui fan, fan choy Glutinous rice e.g. lor mai kai, bak chang Lontong/ketupat Idli (steamed rice cake, savoury) Rice roll e.g. chwee kway, chee cheong fun None of these (You can choose more than one) SPHS - MEC3 ONLINE NUTRITION SURVEY Page Questions Answer options Number How often do you consume Daily Weekly Monthly Rice, plain, boiled/steamed 4+ times 4 - 6 times 2 - 3 times (excluding porridge) 25 2 - 3 times 2 - 3 times 1 time 1 1 time 1 time Which photograph is closest to how much plain rice you eat in a typical meal? How often is the Rice: Always Mostly Mixture of white and brown/red Half the time Sometimes Never/Rarely Always Mostly 26 Brown or red rice (unpolished) Half the time Sometimes Never/Rarely Always Mostly White rice (including basmati) Half the time Sometimes Never/Rarely How often do you consume: Daily Weekly Monthly Flavoured rice porridge 4+ times 4 - 6 times 2 - 3 times e.g.
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