Personalized Evaluation of Fat Intake Self-Assessment Questionnaire

WHI Form 73 Ver. 2 Personalized Evaluation of Fat Intake Self-Assessment Questionnaire

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Date ______Group # ______

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WHI Form 73 – PEFI-Q Ver. 2 Part I: Usual Food Choices

These questions ask about the foods you ate during the PAST MONTH. 1. Did you eat pancakes, waffles, or French toast? 4. Did you eat cornbread, corn muffins, or 7. Did you eat breakfast meats such polenta? as bacon, breakfast sausage, or Yes ➤ 1.a When you ate these soy breakfast “meats”? No foods, how often Yes ➤ 4.a When you ate these grain were they fat-free No foods, how often were they Yes ➤ 7.a When you ate or low-fat? fat-free or low-fat? No breakfast meats, how often were Almost always Almost always they fat-free or Often Often low-fat? Sometimes Sometimes Rarely Rarely Almost always

Never Never Often

➤ ➤ Sometimes 5. Did you eat snack chips such as potato, Rarely Never 2. Did you eat biscuits, muffins, or scones? tortilla, or corn chips? ➤ Yes ➤ 2.a When you ate these Yes ➤ 5.a When you ate snack No breads, how often were No chips, how often were they 8. Did you eat hot dogs or other they fat-free or low-fat? fat-free or low-fat? sausages? Include soy/veggie hot Almost always Almost always dogs or sausages. Often Often Yes ➤ 8.a When you ate hot Sometimes Sometimes No dogs or other Rarely Rarely sausages, how

Never Never ➤ ➤ often were they fat-free or low-fat? 3. Did you eat flour tortillas? 6. Did you eat crackers such as saltines, club, Almost always Ritz¨, or Wheat Thins¨? Yes ➤ 3.a When you ate Often No flour tortillas, how Yes ➤ 6.a When you ate crackers, Sometimes often were they No how often were they fat-free Rarely Never fat-free or low-fat? or low-fat? ➤ Almost always Almost always Often Often Sometimes Sometimes Rarely Rarely

Never Never

➤ ➤

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PLEASE MAKE NO MARKS IN THIS AREA THIS IN MARKS NO MAKE PLEASE SERIAL # SERIAL WHI

9. 10.

During the PAST MONTH... ➤ ➤ poultry, or meatless burgers? Did you eat ground meat, ground Did you eat beef, pork, ham, or lamb? No Yes No Yes ➤ ➤ 10.a 9.a all that apply.) y f When you ate these the fat? often did you eat or lamb, how beef, pork, ham, When you ate oods, what type did ou usually eat? Never Rarely Sometimes Often Almost always bu Regular meatless turkey Ground chicken or ground beef Diet lean or rinsed Extra lean Lean Regular bu Low-fat meatless r r gers gers (Mark

13. 12.

1 Did you use salad dressing? 11.

➤ ➤ potatoes, pasta, or rice? Did you use fat on breads, vegetables, ➤ Did you eat tofu or tempeh (soy products)? Did you eat chicken, turkey, or other poultry? Yes Yes No Yes No No ➤ ➤ ➤ 13.a 12.a 11.a

Form 73 – PEFI-Q CENTER PERF CENTER Pg. 3 of 12 that apply.) y f When you used fat on these they fat-free or low-fat? tempeh, how often were When you ate tofu or often did you eat the skin? turkey, or other poultry, how When you ate chicken, oods, what kind of fat did ou usually use? F Low-fat sour cream Sour cream F Low-fat margarine whipped margarine Whipped butter or or other oil Butter, margarine, olive Never Rarely Sometimes Often Almost always Never Rarely Sometimes Often Almost always at-free sour cream at-free margarine (Mark all

15. 16.

14.

➤ ➤ pasta salad? salads such as tuna, coleslaw, potato, or Did you eat mayonnaise or oil-based ➤ mayonnaise-type spread? Did you use mayonnaise or a No Yes No No Yes Yes ➤ ➤ ➤ 16.a 15.a 14.a that apply.) apply.) usually use? spread, what type did you or a mayonnaise-type When you used mayonnaise y what type of dressing did When you ate these salads, all that apply.) y dressing, what type did When you used salad ou usually use? ou usually use? only No dressing or vinegar F reduced-fat Light, low-fat or vinegar Regular, include oil and F F Low-fat or reduced-fat and vinegar Regular, include oil Light, low-fat or Regular at-free at-free at-free (Mark all that (Mark all (Mark reduced-fat Ver. 2 Ver. 17. 18.

During the PAST MONTH... WHI ➤ ➤ lattes or hot chocolate. include beverages made with milk such as soy, lactose-free, and rice milks. Also Did you drink milk (all types)? and rice milks. cereal? Did you put milk or cream on No Yes Yes No ➤ ➤ Include soy, lactose-free, 18.a 17.a (Mark all that apply.) did you usually use? with milk, what type or beverages made When you drank milk apply.) use? type did you usually cream on cereal, what When you put milk or Whole F 1% 2% f F Non-dairy creamer Cream or half and F 1% 2% Whole at-free half and at-free or 1/2% at-free creamer or at-free or 1/2% (Mark all that Include

21. 20. 19.

➤ ➤ ➤ Did you eat puddings, custards, or flans? Did you eat cookies or cakes? frozen yogurt, sherbet, or ice cream? Did you eat frozen desserts such as sorbet, Yes No Yes Yes No No ➤ ➤ ➤ 21.a 20.a 19.a

Form 73S – PEFI-Q CENTER PERF CENTER Pg. 4 of 12 low-fat? were they fat-free or or cakes, how often When you ate cookies low-fat milk? with fat-free or were they made or flans, how often puddings, custards, When you ate low-fat? were they fat-free or desserts, how often When you ate frozen Never Rarely Sometimes Often Almost always Never Rarely Sometimes Often Almost always Never Rarely Sometimes Often Almost always

3 How often did you eat foods 23. 22. grease, or lard. b Count all fat such as margarine, deep-fried, or cooked in fat? that were pan-fried, ➤ or vegetables? example to fry foods or flavor beans Did you use fat for cooking, for utter, oil, shortening, bacon Yes No 5 or more times per day 4 times per day 3 times per day 2 times per day Once a day 5-6 times per week 3-4 times per week 1-2 times per week Never or less than once per week ➤ 22.a for cooking When you used fat all that apply.) usually use? kind of fat did you as Pam Non-stick spray (such F Low-fat margarine whipped margarine Whipped butter or or shortening Butter, margarine, oil, chorizo sausage pork, ham hock, or meat drippings, salt Lard, bacon fat or at-free margarine ¨ ) , what (Mark Ver. 2 Ver.

CENTER PERF WHI Form 73 – PEFI-Q Ver. 2

24. These questions ask about mixed dishes and soups eaten during the PAST MONTH. When you ate mixed dishes or soups, how often were they prepared to be lower in fat? For example, vegetarian casseroles or mixed dishes made without meats or cheeses or prepared with low-fat or fat-free ingredients.

Mixed Dishes and Soups Did not eat Almost always Often Sometimes Rarely Never low-fat low-fat low-fat low-fat low-fat

a. Stews, casseroles or pot pies such as chicken and rice or chicken and dumplings

b. Pasta or rice dishes with tomato-based sauces such as spaghetti or lasagna

c. Other pasta or rice dishes with cheese, cream, pesto, or sauces, such as

macaroni and cheese or tuna noodle casserole PLEASE MAKE NO MARKS IN THIS AREA THIS IN MARKS NO MAKE PLEASE d. Pizza

e. Asian-style noodle and rice dishes such as fried rice, chow mein, chow fun, or Pad Thai noodles

f. Asian-style (stir-fried) dishes such as sukiyaki, pork, tofu, or chicken long rice

g. Tortilla-based dishes such as enchiladas, chilaquiles, burritos, tacos, tostadas, quesadillas, or chalupas

h. Tamales, chili rellenos, chili con carne, menudo, posole, carne guisada, chicken mole, or pasteles

i. Beans such as red beans, black, navy, pinto, or soybeans (include rice

and beans, refried beans, or vegetarian chili) SERIAL # SERIAL j. Ramen¨ noodles or Ramen¨ noodle soup

k. Cream soups such as chowders, potato, cheese, ajiaco, or coconut soups

l. Bean soups such as pea, lentil, black bean, Portuguese bean, or potajes

Pg. 5 of 12 31. 30. 29. 28. 27. 26. 25. • If you do not eat the food, mark “Never or less than once per month”, and leave the serving size blank. ¥ A large serving is about one-and-a-half (1 1/2) times the medium size. ¥ A small serving is about one-half (1/2) the medium size. ¥ A medium serving size is shown for each food. Please note: Please be aware that these questions ask only about the fat-containing foods This section is about how often you usually ate specific foods. Please think about what you ate during the PAST MONTH. WHI GRAIN PRODUCTS and SALTY SNACKS 2. 1. sandwiches. muffins, or corn tortillas.) Include bread used in White or dark breads (include bagels, rolls, English Flour tortillas (all types) Biscuits, muffins, or scones (all types) Mark your usual serving size as small, medium or large. Mark the column to show how often, on average, you ate the food. Please do not skip any foods. P shrimp chips, pork rinds, or won tons Snack chips (all types) such as potato, tortilla, corn or Cornbread, corn muffins, or polenta (all types) Fried breads such as hush puppies, Indian fry bread, or fritters During the PAST MONTH... ancakes, waffles, or French toast (all types) Pa NEVER or rt less than once per month How Often Did You Eat These Foods? II: Usual Food Use

Form 73 – PEFI-Q CENTER PERF CENTER Pg. 6 of 12 month . They are not meant to look at your total diet. per 1 month per 2-3 week per 1 week per 2 week per 3-4 week per 5-6 day per 1 day per 2+ 1 medium or 2 small biscuits, or 2 tortillas (8-inch) 3 hush puppies or 1 medium muffin 1 waffle (7-inch) 1 medium bagel, Serving Size 2 pancakes or or 2 tortillas 1 medium Medium 2 slices, 1 cup 1 / 2 cup Serving Size? SML Y our Ver. 2 Ver. CENTER PERF WHI Form 73 – PEFI-Q Ver. 2

GRAIN PRODUCTS and SALTY SNACKS (continued) How Often Did You Eat These Foods? Your Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ Serving once per per per per per per per per per Size month monthmonthweek week week week day day SML ¨ ¨ 5-8 crackers 32. Crackers (all types) such as saltines, club, Ritz , or Wheat Thins (about 1 ounce)

33. Air-popped popcorn or fat-free microwave popcorn, no fat added 3 cups

34. Low-fat microwave popcorn, no fat added 3 cups

35. Oil-popped or buttered regular microwave popcorn 3 cups

36. Soy nuts 1/4 cup

37. Peanuts or other nuts and seeds 1/4 cup

MEAT, POULTRY, FISH, and EGGS

Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ Serving once per per per per per per per per per Size month monthmonthweek week week week day day SML 2 eggs or 38. Egg whites or fat-free egg substitutes 1/2 cup 2 eggs or 39. Eggs or egg substitutes containing fat 1/2 cup 40. Breakfast meats (all types) such as bacon, scrapple, 3 strips or breakfast sausage or soy breakfast “meats” 2 links 41. Hot dogs or other sausages such as bratwurst, Vienna, or 2 hot dogs chorizo (all types, include soy) or 3 ounces

42. Fat-free lunchmeats (all types, include soy) 2 slices

43. Low-fat lunchmeats (all types, include soy) 2 slices 44. All other lunchmeats such as bologna, salami, potted or canned meat, or Spam¨ 2 slices

Pg. 7 of 12 WHI Form 73 – PEFI-Q Ver. 2 MEAT, POULTRY, FISH, and EGGS (continued) Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or less than 1 2-3 1 2 3-4 5-6 1 2+ once per per per per per per per per per Medium month monthmonthweek week week week day day Serving Size SML

45. All types of ground meat or ground poultry (include hamburgers, meatloaf, or picadillo) 3 ounces

PLEASE MAKE NO MARKS IN THIS AREA THIS IN MARKS NO MAKE PLEASE 46. All types of beef, pork, ham, or lamb (include ribs 4 ounces or corned beef)

47. Liver, chicken liver, or organ meats such as tripe 4 ounces

48. Chicken, turkey, or other poultry (roasted, stewed, or broiled) 3 ounces 3 ounces or 49. Fried chicken, include nuggets, tenders, or chicken katsu 6 nuggets 50. Fried fish, fish sandwich, or fried shellfish (shrimp, 3 ounces or oysters) 1 sandwich

51. Shellfish, not fried (shrimp, lobster, crab, or oysters) 3 ounces or 1/2 cup 52. White fish (broiled, baked, or canned) such as sole, halibut, or water-packed tuna 3 ounces

53. Dark fish (broiled, baked, or canned) such as salmon, 3 ounces

mackerel, bluefish, or oil-packed tuna SERIAL # SERIAL 54. Laulau 1 medium

55. Dim sum (steamed or baked) such as manapua, 3 pieces or char si bao, or pork hash 1 medium

56. Egg rolls, lumpia, dim sum (fried varieties), or cone 1 medium or sushi with fried tofu wrap 1 small cone

57. Tofu or tempeh (all types) 3 slices or 3 ounces

Small (2 ounces) Medium (4 ounces) Large (6 ounces)

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CENTER PERF WHI Form 73 – PEFI-Q Ver. 2

FATS USED AT THE TABLE or ADDED IN COOKING

Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ Serving Size once per per per per per per per per per month monthmonthweek week week week day day SML

58. Butter or margarine (all types) on breads, pancakes, or hot cereals 2 pats or 2 tsp.

59. Butter, margarine or sour cream (all types) added to vegetables, 2 pats or 2 tsp. potatoes, pasta, or rice

60. Reduced-fat peanut butter 2 Tbsp.

61. Peanut butter 2 Tbsp.

62. Salad dressing (all types) 2 Tbsp.

1/ medium 63. Avocado or guacamole 4 or 1/4 cup

64. Low-fat cheese sauce or low-fat cream sauce 1/4 cup

65. Cheese, cream, or coconut sauces 1/4 cup

66. Low-fat meat gravies 1/4 cup

67. Meat gravies 1/4 cup

68. Mayonnaise or oil-based salads such as tuna, coleslaw, potato 1/ cup or pasta salad (include German potato salad) 2

69. Mayonnaise or mayonnaise-type spreads (all types) 2 Tbsp.

70. Fried vegetables, such as deep-fat fried onions, zucchini, 3/ cup okra, plantains, or cassava 4

71. French fries or other fried potatoes 3/4 cup

Pg. 9 of 12 WHI Form 73 – PEFI-Q Ver. 2

MIXED DISHES and SOUPS

Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ Serving Size (Include all types) once per per per per per per per per per month monthmonthweek week week week day day SML

PLEASE MAKE NO MARKS IN THIS AREA THIS IN MARKS NO MAKE PLEASE 72. Stews, casseroles or pot pies such as chicken and rice or 1 cup chicken and dumplings

73. Pasta or rice dishes with tomato-based sauces such as 1 cup spaghetti or lasagna

74. Other pasta or rice dishes with cheese, cream, pesto, or sauces, 1 cup such as macaroni and cheese, or tuna noodle casserole 2 slices of 75. Pizza a 12" pizza 76. Asian-style noodle and rice dishes such as fried rice, chow 1 cup mein, chow fun, or Pad Thai noodles

77. Asian-style (stir-fried) dishes such as sukiyaki, pork, 1 cup tofu, or chicken long rice

78. Tortilla-based dishes such as enchiladas, chilaquiles, burritos, 2 enchiladas tacos, tostadas, quesadillas, or chalupas or 1 medium

79. Tamales, chili rellenos, chili con carne, menudo, posole,

SERIAL # SERIAL 1 cup or carne guisada, chicken mole, or pasteles 1 medium 80. Beans such as red beans, black, navy, pinto or soybeans 1 cup (include rice and beans, refried beans, or vegetarian chili)

81. Ramen¨ noodles or Ramen¨ noodle soup 1 cup

82. Vegetable, minestrone, tomato, or noodle soup 1 cup

1 1 Small ( /2cup) Medium (1 cup) Large (1 /2 cups)

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MIXED DISHES and SOUPS (continued) Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ Serving Size once per per per per per per per per per month monthmonthweek week week week day day SML

83. Cream soups such as chowders, potato, cheese, ajiaco, or coconut soups 1 cup

84. Bean soups, such as pea, lentils, black bean, Portuguese bean, or potajes 1 cup

MILK, CHEESE, and YOGURT

85. Milk or cream on cereals (all types of milk) 1/2 cup

86. Fat-free cottage cheese or ricotta cheese 1/2 cup

87. Low-fat cottage cheese or ricotta cheese 1/2 cup

88. Cottage cheese or ricotta cheese 1/2 cup 2 slices or 89. Fat-free cheeses (include fat-free soy cheeses) 1/4 cup shredded 90. Low-fat cheeses such mozzarella (include 2 slices or low-fat soy cheeses) 1/4 cup shredded

91. All other cheeses such as American, cheddar, 2 slices or or cream cheese (include full-fat soy cheeses) 1/4 cup shredded

92. Fat-free yogurt (except frozen) 1 cup

93. All other yogurt (except frozen) 1 cup

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SWEETS

Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than 1 2-3 1 2 3-4 5-6 1 2+ once per per per per per per per per per Serving Size

month monthmonthweek week week week day day SML PLEASE MAKE NO MARKS IN THIS AREA THIS IN MARKS NO MAKE PLEASE

94. Frozen desserts (all types) such as frozen 3/4 cup yogurt, sherbet, ice cream or milkshakes or 1 shake

95. Pudding, custards, or flans (all types) 3/4 cup

96. Pies, fried pastries, doughnuts, fruit empanadas, 1 medium slice pan dulce, or malasades or 1 piece 3 small or 97. Cookies or cakes (all types) 1 large cookie, or 1 piece of cake 98. Low-fat chocolate and candy bars such as Milky 1 regular bar Way Lite¨, and York¨ peppermint patties or 4 pieces 1 regular bar 99. Chocolate, candy bars, and toffee or 4 pieces

MILK as BEVERAGES SERIAL # SERIAL Your How Often Did You Eat These Foods? Serving Size? During the PAST MONTH... NEVER or Medium less than1-3 1 2-4 5-6 1 2-3 4-5 6+ Serving Size (NOTE: The frequency headings are ➤ once perper per per per per per perper different.) month monthweek week week day day dayday SML

100. Milk as beverage 1 cup

101. Latte, cappuccino, mocha, or hot chocolate 1 cup

102. Milk, cream, or creamer added to tea or coffee 1 Tbsp.

Thank you! Please take a moment to review your questionnaire and fill in any questions you may have skipped.

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