Personalized Evaluation of Fat Intake Self-Assessment Questionnaire
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WHI Form 73 Ver. 2 Personalized Evaluation of Fat Intake Self-Assessment Questionnaire Name ____________________________________________ Date ________________________ Group # ________________________ Please use pencil. Answer by filling in the circle that best represents your answer. Yes No Do not make any other marks on the form. CENTER PERF OFFICE USE ONLY: 1. Date Completed: M 1 2 3 4 5 6 7 8 9 10 11 12 10 20 30 D 1 2 3 4 5 6 7 8 9 Month Day Year Y 02 03 04 2. Reviewed By: 100 200 300 10 20 30 40 50 60 70 80 90 1 2 3 4 5 6 7 8 9 3. Contact Type: 2 Mail 6. FGG: (optional field) 3 Visit 8 Other 10 20 30 40 50 60 70 80 90 1 2 3 4 5 6 7 8 9 4. Visit Type: 6 Intervention 5. Language: BAR CODE HERE 2 U.S. GOVERNMENT PRINTING OFFICE:2003-589-322/40016 ES ★ AFFIX LABEL BETWEEN LINES SERIAL # PLEASE MAKE NO MARKS IN THIS AREA R:\FORMS\F73V2.DOC 9/1/03 Pg. 1 of 12 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 ➤ ➤ Pg. 2 of 12 CENTER PERF CENTER PERF WHI Form 73 – PEFI-Q Ver. 2 During the PAST MONTH... 11.Did you eat chicken, turkey, or other poultry? 14. Did you use salad dressing? ➤ ➤ 9. Did you eat ground meat, ground Yes 11.a When you ate chicken, Yes 14.a When you used salad No No poultry, or meatless burgers? turkey, or other poultry, how dressing, what type did often did you eat the skin? you usually use? (Mark ➤ Yes 9.a When you ate these all that apply.) No foods, what type did Almost always you usually eat? (Mark Often Regular, include oil all that apply.) Sometimes and vinegar Rarely Low-fat or reduced-fat Never Fat-free ➤ ➤ Regular Lean 12. Did you eat tofu or tempeh (soy products)? Extra lean 15. Did you eat mayonnaise or oil-based Diet lean or rinsed Yes ➤ 12.a When you ate tofu or salads such as tuna, coleslaw, potato, or ground beef No tempeh, how often were Ground chicken or pasta salad? PLEASE MAKE NO MARKS IN THIS AREA PLEASE MAKE NO MARKS they fat-free or low-fat? turkey Yes ➤ 15.a When you ate these salads, Regular meatless Almost always No what type of dressing did burgers Often you usually use? (Mark all Low-fat meatless Sometimes that apply.) burgers Rarely ➤ Never Regular, include oil and ➤ vinegar 10. Did you eat beef, pork, ham, or lamb? 13. Did you use fat on breads, vegetables, Light, low-fat or reduced-fat potatoes, pasta, or rice? Yes ➤ 10.a When you ate Fat-free No beef, pork, ham, Yes ➤ 13.a When you used fat on these No dressing or vinegar only or lamb, how No foods, what kind of fat did ➤ often did you eat you usually use? (Mark all the fat? that apply.) 16. Did you use mayonnaise or a Almost always Butter, margarine, olive mayonnaise-type spread? Often or other oil Yes ➤ 16.a When you used mayonnaise SERIAL # Sometimes Whipped butter or No or a mayonnaise-type Rarely whipped margarine spread, what type did you Never Low-fat margarine ➤ usually use? (Mark all that Fat-free margarine apply.) Sour cream Low-fat sour cream Regular Fat-free sour cream Light, low-fat or reduced-fat ➤ Fat-free ➤ Pg. 3 of 12 WHI Form 73S – PEFI-Q Ver. 2 During the PAST MONTH... 19. Did you eat frozen desserts such as sorbet, 22. Did you use fat for cooking, for frozen yogurt, sherbet, or ice cream? example to fry foods or flavor beans 17. Did you put milk or cream on or vegetables? cereal? Include soy, lactose-free, Yes ➤ 19.a When you ate frozen Yes ➤ 22.a When you used fat and rice milks. No desserts, how often No for cooking, what Yes ➤ 17.a When you put milk or were they fat-free or kind of fat did you No cream on cereal, what low-fat? usually use? (Mark type did you usually all that apply.) use? (Mark all that Almost always Often Lard, bacon fat or apply.) Sometimes meat drippings, salt Whole Rarely pork, ham hock, or 2% Never chorizo sausage ➤ 1% Butter, margarine, oil, Fat-free or 1/2% 20. Did you eat puddings, custards, or flans? or shortening Cream or half and half Whipped butter or Non-dairy creamer Yes ➤ 20.a When you ate whipped margarine Fat-free creamer or No puddings, custards, Low-fat margarine fat-free half and half Fat-free margarine ➤ or flans, how often were they made Non-stick spray (such as Pam®) 18. Did you drink milk (all types)? Include with fat-free or soy, lactose-free, and rice milks. Also low-fat milk? ➤ include beverages made with milk such as Almost always 23. How often did you eat foods lattes or hot chocolate. Often Sometimes that were pan-fried, Rarely deep-fried, or cooked in fat? ➤ 18.a Never Count all fat such as margarine, Yes When you drank milk ➤ No or beverages made butter, oil, shortening, bacon grease, or lard. with milk, what type 21. Did you eat cookies or cakes? did you usually use? ➤ Never or less than once per week (Mark all that apply.) Yes 21.a When you ate cookies No or cakes, how often 1-2 times per week Whole were they fat-free or 3-4 times per week 2% low-fat? 5-6 times per week 1% Once a day Fat-free or 1/2% Almost always 2 times per day ➤ Often 3 times per day Sometimes 4 times per day Rarely 5 or more times per day Never ➤ Pg. 4 of 12 CENTER PERF 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 PLEASE MAKE NO MARKS 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 # 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 WHI Form 73 – PEFI-Q Ver. 2 Part II: Usual Food Use This section is about how often you usually ate specific foods. Please think about what you ate during the PAST MONTH. Please be aware that these questions ask only about the fat-containing foods. They are not meant to look at your total diet. 1. Mark the column to show how often, on average, you ate the food.