Expiration Date 7/31/2006

DIET QUESTIONNAIRE OMB No. 0925-0522 National Institute of Environmental Health Sciences National Institutes of Health Department of Health and Human Services

INSTRUCTIONS: This form is about foods you usually eat. It will take approximately 50 minutes to complete. Please answer each question as best you can. ¥ Use the enclosed pencil or any No. 2 pencil for • Estimate if you aren't sure. this form ¥ Fill in ovals completely and erase completely if you make changes • Please give your completed form to the EMSI examiner. CORRECT: INCORRECT: ✓ ✗

FOR OFFICE USE ONLY: ¥ PLEASE KEEP THIS QUESTIONNAIRE CLEAN, FLAT AND DRY. If this form was completed by DO NOT FOLD OR TEAR ANY OF THE PAGES. telephone, check here ¥

Interviewer's initials:

AGE WEIGHT HEIGHT TODAY'S DATE pounds ft. in. DAY YEAR Jan Feb 0 0 0 0 0 00 Mar 0 0 2005 1 1 1 1 1 01 Apr 1 1 2006 PLACE 2 2 2 2 2 02 May 2 2 2007 Review3 3 Copy3 3 3 3 03 3 3 Jun 2008 4 4 4 4 4 4 04 Jul 4 2009 5 5 5 5 5 05 5 LABEL Aug 2010 Do not use without6 6 6 6 6permission06 Sep 6 2011 7 7 7 7 07 Oct 7 2012 8 8 8 8 08 Nov 8 2013 9 9 9 9 09 Dec 9 2014 HERE 10 11

Are you pregnant or No breast feeding? Yes

IF YOU HAVE ANY QUESTIONS ABOUT THIS QUESTIONNAIRE, PLEASE CALL US TOLL-FREE AT 1-877-4SISTER (1-877-474-7837). Public reporting burden for this collection of information is estimated to average 50 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0522). Do not return the completed form to this address. PLEASE DO NOT WRITE IN THIS AREA SERIAL #

Block © 2003 BDDS Form #03; Version #02 AVERAGE USE IN THE PAST 12 MONTHS LESS First, a few general questions THAN 1-2 3-4 5-6 1 1 1/2 2 3 4+ about what you eat. ONCE per per per per per per per per per WEEK WEEK WEEK DAY DAY DAY DAY DAY WEEK

About how many servings of vegetables Please use a #2 pencil for this form do you eat, per day or per week, not counting salad or potatoes? About how many servings of fruit do you eat, not counting juices? How often do you eat cold cereal?

How often do you use fat or oil in cooking?

What kinds of fat or oil do you usually use in cooking? MARK ONLY ONE OR TWO Don't use fats/oils Stick margarine Butter/margarine blend Olive oil or canola oil Don't know Soft tub margarine Low-fat margarine Lard, fatback, bacon fat Pam Butter Corn oil, vegetable oil Crisco

During the past year, on average, how many <1/wk 1-2/wk 3-4/wk 5-6/wk 1/day days per week did you eat: Breakfast?

Lunch?

Dinner/Supper?

During the past year, on average, how many days per week did you have a snack? Don't count breakfast, Review Copy<1/wk 1-2/wk 3-4/wk 5-6/wk 1/day lunch and dinner/supper. Do count all beverages EXCEPT coffee, tea, diet drinks and water. BeforeDo Breakfast? not use without permission Between Breakfast - Lunch?

Between Lunch - Dinner/Supper?

Between Supper and Bedtime?

After Bedtime?

Block © 2003 BDDS PAGE 2 During the past 12 months, have you taken any vitamins or minerals regularly, at least once a month? No, not regularly Yes, fairly regularly

(IF YES) WHAT DID YOU TAKE FAIRLY REGULARLY? VITAMIN TYPE HOW OFTEN FOR HOW MANY YEARS? A FEW 1-3 4-6 DAYS DAYS DAYS LESS DIDN'T per per per EVERY THAN 1 2 3-4 5-9 10+ TAKE MONTH WEEK WEEK DAY 1 YR. YEAR YEARS YEARS YEARS YEARS Multiple Vitamins. Did you take… Regular Once-A-Day, Centrum, or Thera type Stress-tabs or B-Complex type Antioxidant combination type Single Vitamins (not part of multiple vitamins) Vitamin A (not beta-carotene) Beta-carotene Thiamin (B1) Niacin (B3) Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Folic acid, folate Calcium, alone or combined with something else Chromium Iron Magnesium Selenium Zinc, alone or combined with something else

Please use a #2 pencil for this form

If you took Once-a-day, Centrum or Thera-type contain minerals, do not contain don't multiple vitamins, did youReview usually take types that Copyiron, zinc, etc. minerals know If you took vitamin C, vitamin D or vitamin E: How many milligrams of vitamin C did you usually take, on the days you took it? 100 250 500 750 1000 1500 2000 3000+ Don't know DoHow many IU'snot of vitamin use D did you usually without take, on the days you took permission it? 100 200 400 600 800+ Don't know How many IUs of vitamin E did you usually take, on the days you took it? 100 200 300 400 600 800 1000 2000+ Don't know

Did you take any of these supplements at least once a month? (Mark all that apply.) Arnica (any form) DHEA Ginkgo Milk thistle Astragalus Dong quai Ginseng Saw palmetto Black Cohosh Echinacea Glucosamine/ Mistletoe (Iscador) injections Chinese herbal medicine Ephedra (ma huang) Chondroitin Shark cartilage Co-enzyme Q10 (CoQ10) Evening primrose oil Hydrazine sulfate St. John's Wort Comfrey Fish oil, EPA, omega-3 Kava Kava Turmeric capsules Cranberry pills or cod liver oil Lecithin Valarian Creatine Garlic pills Melatonin Something else Didn't take these

Have you used any of the following complementary or alternative practices within the past 12 months? (Mark all that apply.) homeopathic remedies juicing acupuncture yoga spirituality, therapeutic touch/massage Tai chi Qi gong chiropractic meditation, prayer

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PAGE 3 HOW TO FILL OUT THIS QUESTIONNAIRE The next section is about your usual habits in the past 12 months or so. This includes all meals or snacks, at home or in a restaurant or carry-out. There are two kinds of questions to answer for each food: HOW OFTEN, on average, did you eat the food during the past 12 months? Please use a #2 pencil for this form *Please DO NOT SKIP any foods. Mark "Never" if you didn't eat it. HOW MUCH did you usually eat of the food? *Sometimes we ask how many you eat, such as 1 egg, 2 eggs, etc., ON THE DAYS YOU EAT IT. *Sometimes we ask "how much" as A, B, C or D. LOOK AT THE ENCLOSED PICTURES. For each food, pick the picture (bowls or plates) that looks the most like the serving size you usually eat. (If you don't have pictures: A=1/4 cup, B=1/2 cup, C=1 cup, D=2 cups.) *Sometimes we made the "D" column a darker color. This is just to remind you to make sure you really eat that large a serving. EXAMPLE: This person drank apple juice twice a week, and had one glass each time. Once a week he ate a "C" sized serving of rice (about 1 cup). A FEW 2-3 3-4 5-6 HOW OFTEN IN THE TIMES ONCE TIMES ONCE TWICE TIMES TIMES HOW MUCH EACH TIME NEVER EVERY SEE PORTION SIZE PAST 12 MONTHS per per per per per per per DAY YEAR MON. MON. WEEK WEEK WEEK WEEK PICTURES FOR A-B-C-D How many glasses Apple juice each time 1 2 3 4 Rice How much each time A B C D Begin food questionnaire

A FEW 2-3 2 3-4 5-6 HOW MUCH EACH TIME TIMES ONCE TIMES ONCE TIMES TIMES TIMES HOW OFTEN NEVER EVERY IN THE PAST 12 MONTHS per per per per per per per DAY How many glasses on the YEAR MONTH MONTH WEEK WEEK WEEK WEEK days you drink it?

How often do you drink the following beverages? How many Tomato juice or V-8 juice glasses 1 2 3 4 Real 100% orange juice or grapefruit How many juice, including fresh, frozen orReview bottled Copy glasses 1 2 3 4 When you drink orange juice, how often do Usually calcium-fortified I don't know you drinkDo a calcium-fortified not brand? use withoutSometimes calcium-fortified permissionI don't drink orange juice Hardly ever calcium-fortified Other real fruit juices like apple How many juice, prune juice, lemonade glasses 1 2 3 4

Kool-Aid, Hi-C, or other How many drinks with added vitamin C glasses 1 2 3 4 Drinks with some juice in them, How many like Sunny Delight, Juice Squeeze bottles 1 2 3 4 Instant breakfast milkshakes like How many Carnation, diet shakes like SlimFast, glasses or or liquid supplements like Ensure cans 1 2 3 4

How many Glasses of milk (not including soy milk) glasses 1 2 3 4 When you drink glasses of milk, what kind do you usually drink? MARK ONLY ONE: Whole milk Reduced-fat 2% milk Non-fat milk Rice milk Low-fat 1% milk I don't drink milk

PAGE 4 A FEW 2-3 2 3-4 5-6 HOW MUCH EACH TIME TIMES ONCE TIMES ONCE TIMES TIMES TIMES HOW OFTEN NEVER EVERY IN THE PAST 12 MONTHS per per per per per per per DAY How many glasses on the YEAR MONTH MONTH WEEK WEEK WEEK WEEK days you drink it? Beverages (continued) Regular soft drinks, or bottled How many bottles or drinks like Snapple (not diet drinks) 1 2 3-4 5+ cans How many Beer or non-alcoholic beer bottles or cans 1 2 3-4 5+ What kind? MARK ONLY ONE: Regular beer Light beer Non-alcoholic beer I don't drink beer How many Wine or wine coolers glasses 1 2 3-4 5+ How many Liquor or mixed drinks drinks 1 2 3-4 5+ How many Glasses of water, tap or bottled glasses 1 2 3-4 5+ How many Coffee, regular cups 1 2 3-4 5+ How many Coffee, decaf cups 1 2 3-4 5+ How many Tea or iced tea (not herb teas) cups 1 2 3-4 5+ How many Chapparal tea (creosote bush) cups 1 2 3-4 5+ How many Essiac tea cups 1 2 3-4 5+ How many Green tea cups 1 2 3-4 5+ How many Pau d'Arco Please use a #2 pencil for this form cups 1 2 3-4 5+ What do you usually add to coffee? MARK ONLY ONE: ReviewCream or half & halfCopyNondairy creamer Milk None of these What do you usually add to tea? Cream or half & half Nondairy creamer Milk None of these MARKDo ONLY ONE: not use without permission Do you usually add sugar (or honey) to coffee? No Yes IF YES, how many teaspoons each cup? 1 2 3-4 5+

Do you usually add sugar (or honey) to tea? No Yes IF YES, how many teaspoons each cup? 1 2 3-4 5+

A FEW 2-3 2 3-4 5-6 HOW OFTEN HOW MUCH EACH TIME NEVER TIMES ONCE TIMES ONCE TIMES TIMES TIMES WHEN IN SEASON per per per per per per per EVERY SEE PORTION SIZE YEAR MONTH MONTH WEEK WEEK WEEK WEEK DAY PICTURES FOR A-B-C-D How often do you eat each of the following fruits, just during the 2-3 months when they are in season?

Raw peaches, apricots, nectarines, How many while they are in season each time 1/2 1 2 3 Cantaloupe, in season How much 1/8 1/4 1/2 1 Strawberries, in season How much A B C D Watermelon, in season How much A B C D Any other fruit in season, like How much grapes, honeydew, pineapple, kiwi A B C D

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PAGE 5 A FEW 2-3 2 3-4 5-6 HOW OFTEN HOW MUCH EACH TIME NEVER TIMES ONCE TIMES ONCE TIMES TIMES TIMES IN THE PAST 12 MONTHS per per per per per per per EVERY SEE PORTION SIZE YEAR MONTH MONTH WEEK WEEK WEEK WEEK DAY PICTURES FOR A-B-C-D How often do you eat the following foods all year round? Estimate your average for the past 12 months.

How many Please use a #2 pencil for this form Bananas each time 1/2 1 2 3 Apples or pears How many each time 1/2 12 3 How many Oranges or tangerines each time 1/2 1 2 3 Grapefruit How much 1/2 1 23 Canned fruit like applesauce, fruit How much cocktail, or dried fruit like raisins A B C D

FEW/ ONCE/ 2-3 ONCE/ TWICE/ 3-4 5-6 EVERY HOW OFTEN NEVER YEAR MONTH TIMES/ WEEK WEEK TIMES/ TIMES/ DAY HOW MUCH EACH TIME MONTH WEEK WEEK Eggs, including egg biscuits or Egg How many McMuffins (Not egg substitutes) eggs each time 1 2 3 4 How many Bacon pieces 1 2 3 4 Breakfast sausage, including How many sausage biscuits pieces 1 2 3 4 Pancakes, waffles, French toast, How many Pop Tarts pieces 1 2 3 4 Breakfast bars, granola bars, How many Power Bars or other energy bars 1 2 3 4 Cooked cereals like oatmeal, Which bowl cream of wheat or grits B C D High-fiber cereals like All Bran, Which bowl Raisin Bran, Fruit-n-Fiber B C D

Which high-fiber cereal do you eat most often? MARK ONLY ONE: All Bran or Bran Buds Raisin Bran Fiber One, Fruit-n-Fiber, etc. ReviewSomething else CopyI don't know I don't eat it Product 19, Just Right or Which bowl Total cereal B C D Any other cold cereal, like Corn Do not use without permissionWhich bowl Flakes, Cheerios, Special K B C D Milk or milk substitutes on cereal How many oz. on cereal 3 oz. 4-5 oz. 6-7 oz. 8+ oz. Yogurt or frozen yogurt How much A B C D Cheese, sliced cheese or cheese How many spread, including on sandwiches slices 1 2 3 4 When you eat cheese, is it Usually low-fat Sometimes low-fat Hardly ever low-fat Don't know/don't eat

PAGE 6 A FEW 2-3 2 3-4 5-6 HOW MUCH EACH TIME TIMES ONCE TIMES ONCE TIMES TIMES TIMES HOW OFTEN NEVER EVERY SEE PORTION SIZE per per per per per per per DAY IN THE PAST 12 MONTHS YEAR MONTH MONTH WEEK WEEK WEEK WEEK PICTURES FOR A-B-C-D How often do you eat the following vegetables, including fresh, frozen, canned or in stir-fry, at home or in a restaurant? How Broccoli much A B C D Carrots, or mixed vegetables or How stews containing carrots much A B C D How Corn much A B C D How Green beans or green peas much A B C D How Spinach much A B C D Mustard greens, turnip greens, collards How much A B C D French fries, fried potatoes or hash browns How much A B C D White potatoes not fried, incl. boiled, How baked, mashed & potato salad much A B C D Sweet potatoes, yams (Not in pie) How much A B C D Cole slaw, cabbage How much A B C D Green salad How much A B C D Raw tomatoes, including in salad How much 1/4 1/2 1 2 How Salad dressing many Please use a #2 pencil for this form Tbsp. 1234 Is your salad dressing Usually low-fat Sometimes low-fat Hardly ever low-fat Don't know/don't use

Any other vegetable, like okra, squash, How cooked green peppers Review Copy much A B C D FEW/ ONCE/ 2-3 ONCE/ TWICE/ 3-4 5-6 EVERY HOW OFTEN NEVER YEAR MONTH TIMES/ WEEK WEEK TIMES/ TIMES/ DAY HOW MUCH EACH TIME MONTH WEEK WEEK How RefriedDo beans or beannot burritos use without permissionmuch A B C D Chili with beans (with or without meat) How much A B C D Baked beans, black-eye peas, How pintos, any other dried beans much A B C D Vegetable stew Which Bowl B C D Vegetable soup, vegetable beef, Which chicken vegetable, or tomato soup Bowl B C D Split pea, bean or lentil soup Which Bowl B C D Any other soup, like chicken noodle, Which chowder, mushroom, instant soups Bowl B C D Spaghetti, lasagna or other pasta How with tomato sauce much A B C D Cheese dishes without tomato How sauce, like macaroni and cheese much A B C D How Pizza, including carry-out many slices 1 2 3 4

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PAGE 7 A FEW 2-3 2 3-4 5-6 HOW MUCH EACH TIME HOW OFTEN TIMES ONCE TIMES ONCE TIMES TIMES TIMES EVERY NEVER SEE PORTION SIZE IN THE PAST 12 MONTHS per per per per per per per DAY YEAR MONTHMONTH WEEK WEEK WEEK WEEK PICTURES FOR A-B-C-D

Do you ever eat chicken, turkey, meat or fish? Yes No IF NO, SKIP TO NEXT PAGE

Hamburgers, cheeseburgers, meat How much Please use a #2 pencil for this form loaf, at home or in a restaurant meat 1/8 lb. 1/4 lb. 1/2 lb. 3/4 lb. Tacos, burritos, enchiladas, How tamales, etc. with meat or chicken much A B C D Beef steaks, roasts, pot roast, beef barbecue, or in frozen How much dinners or sandwiches A B C D Pork, pork chops, pork roasts, pork barbecue, dinner ham or in How much frozen dinners A B C D When you eat meat, do you Avoid eating the fat Sometimes eat the fat Often eat the fat I don't eat meat

Veal, lamb or deer meat How much A B C D Ribs, spareribs How many ribs 3-4 5-6 7-8 9+ Liver, including chicken livers How or liverwurst much A B C D Gizzard, pork neckbones, chitlins, How pigs feet, oxtail, tongue much A B C D Mixed dishes with beef or pork, like How stew, corned beef hash, stuffed much A B C D cabbage, meat dish with noodles Mixed dishes with chicken, like chicken casserole, chicken & How noodles, pot pie or in stir-fry much A B C D Fried chicken or chicken nuggets, # medium at home or in a restaurant pieces 1 2 3 4 Chicken or turkey not fried, such as How baked, grilled, or on sandwiches much A B C D When you eat Review Copy Avoid eating the skin Sometimes eat the skin Often eat the skin I don't eat chicken chicken, do you FEW/ ONCE/ 2-3 ONCE/ TWICE/ 3-4 5-6 EVERY HOW OFTEN NEVER YEAR MONTH TIMES/ WEEK WEEK TIMES/ TIMES/ DAY HOW MUCH EACH TIME Do not use withoutMONTH WEEK permissionWEEK Oysters How much A B C D Other shellfish like shrimp, How scallops, crabs much A B C D Tuna, tuna salad, tuna casserole How much of the tuna A B C D Fried fish or fish sandwich, at home How or in a restaurant much A B C D How Other fish, not fried much A B C D Hot dogs, or sausage like Polish, How Italian or chorizos many 1 2 3 4 Are your hot dogs Usually low-fat Sometimes low-fat Hardly ever low-fat Don't know/don't eat them Boloney, sliced ham, turkey How many lunch meat, other lunch meat slices 1 2 3 4 Are your Usually low-fat or turkey Sometimes low-fat Hardly ever low-fat I don't eat lunch meat lunch meats Menudo, pozole, caldo de res, How sancocho, ajiaco much A B C D

PAGE 8

A FEW 2-3 2 3-4 5-6 HOW MUCH EACH TIME HOW OFTEN NEVER TIMES ONCE TIMES ONCE TIMES TIMES TIMES EVERY IN THE PAST 12 MONTHS per per per per per per per DAY SEE PORTION SIZE YEAR MONTH MONTH WEEK WEEK WEEK WEEK PICTURES FOR A-B-C-D How Noodles, macaroni, pasta salad much A B C D Chinese food, Thai or other Asian How food, not counted above much A B C D Snacks like potato chips, corn How chips, popcorn (not pretzels) much A B C D Are these snacks Usually low-fat Sometimes low-fat Hardly ever low-fat Don't know/don't eat

How Peanuts, other nuts or seeds much A B C D How Crackers much A B C D How Doughnuts, Danish pastry many 1 2 3 4 How Cake, sweet rolls, coffee cake much A B C D Are they Usually low-fat Sometimes low-fat Hardly ever low-fat Don't know/don't eat

How Cookies many 1-2 3-5 6-7 8+ Are your cookies Usually low-fat Sometimes low-fat Hardly ever low-fat I don't know/don't eat How Ice cream, ice milk, ice cream bars much A B C D Is your ice cream Usually low-fat Sometimes low-fat Hardly ever low-fat I don't know/don't eat How many Pumpkin pie, sweet potato pie Please use a #2 pencil for this form slices 1/2 1 2 3 How many Any other pie or cobbler slices 1/2 1 2 3 How many Chocolate candy, candy bars bars 1 1 1 2 Review Copy smallmedium large large Other candy, not chocolate, like How many hard candy, caramel, jelly beans pieces Do not use without permission1-2 3-5 6-7 8+

PAGE 9 NEVER HOW MUCH EACH TIME HOW OFTEN OR A 2-3 2 3-4 5-6 EVERY 2+ FEW ONCE TIMES ONCE TIMES TIMES TIMES DAY TIMES SEE PORTION SIZE IN THE PAST 12 MONTHS TIMES per per per per per per per PER PICTURES FOR A-B-C-D YEAR MONTH MONTH WEEK WEEK WEEK WEEK DAY

Biscuits or muffins How many

1 2 3 4 Please use a #2 pencil for this form Rolls, hamburger buns, English How many muffins, bagels 1/2 123 Dark bread like rye or whole How many wheat, including in sandwiches slices 1 2 3 4 White bread or toast, including How many French, Italian, or in sandwiches slices 1 2 3 4 Corn bread, corn muffins, How many or hushpuppies pieces 1 2 3 4

Tortillas How many 1 2 3 4

Rice, or dishes made with rice How much A B C D Margarine (not butter) on bread or How many on potatoes or vegetables, etc. pats (tsp.) 1 2 3 4 Butter (not margarine) on bread or How many on potatoes or vegetables, etc. pats (tsp.) 1 2 3 4 How Gravy many Tbsp. 1 2 3 4 How Peanut butter many Tbsp. 1 2 3 4 How Jelly, jam, or syrup many Tbsp. 1 2 3 4 How Mayonnaise, sandwich spreads many Tbsp. 1 2 3 4 How Catsup, salsa or chile peppers many Tbsp. 1 2 3 4 Mustard, soy sauce, steak sauce, How many Tbsp. barbecue sauce, other sauces Review Copy 1 2 3 4 Do not use without permission

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PAGE 10 Soy Foods

A FEW 2-3 3-4 5-6 HOW MUCH EACH TIME HOW OFTEN EVERY NEVER TIMES ONCE TIMES ONCE TWICE TIMES TIMES IN THE PAST 12 MONTHS per per per per per per per DAY SEE PORTION SIZE YEAR MONTH MONTH WEEK WEEK WEEK WEEK PICTURES FOR A-B-C-D

How often do you eat each of the following foods? Tofu, bean curd, or tempeh How much A B C D Meat substitutes made from soy, How much including Morningstar Farms or Boca A BCD Burgers, vegetarian hot dogs, vegetarian lunch meats, or soy cheese. How many Soy milk, any flavor glasses on those days 1 2 3 4 Energy bars, including Luna, Oasis, How many Protein Plus or 'Tiger's Milk' 1 2 3 4 Miso soup Which bowl B C D Soy sauce # Tbsp. 1 2 3 4 Edamame, boiled green soybeans How much A B C D Soynuts, roasted soybeans How much A B C D How many Soy protein powder scoops 1 2 3-4 5+ How many Soy isoflavone tablets or capsules pills 1 2 3-4 5+

Please use a #2 pencil for this form # Tbsp. Flaxseeds each time 1 2 3 4 # Tbsp. Flaxseed oil each time 1 2 3 4 Review Copy # Tbsp. Flaxseed meal each time 1-2 3-4 5-6 7+ In the past year have you made an effort to include soy foods or supplements in your diet? DoNO notYES use without permission

PAGE 11 A FEW 2-3 2 3-4 5-6 HOW OFTEN TIMES NEVER ONCE TIMES ONCE TIMES TIMES TIMES EVERY IN THE PAST 12 MONTHS PER per per per per per per DAY YEAR MONTH MONTH WEEK WEEK WEEK WEEK How often did you… Please use a #2 pencil for this form Eat “fast-food” from restaurants like McDonald’s or Kentucky Fried Chicken? Eat food from other restaurants - either at the restaurant or take-out/delivery? Eat frozen meals (TV dinner type)?

When you eat produce, is it usually…? Fresh Frozen Canned

When you eat produce, how often do you usually eat ORGANIC produce? Never More than half of the time Less than half of the time I don’t eat produce About half of the time

When you eat meat, how often do you usually eat ORGANIC meat? Never More than half of the time Less than half of the time I don’t eat meat About half of the time

When you consume dairy products, how often do you usually consume ORGANIC dairy products? Never More than half of the time Less than half of the time I don’t consume dairy products About half of the time Review Copy

CookingDo Practices not use without permission

LESS ABOUT MORE I THAN THAN DON’T When you eat/prepare the following vegetables, HALF NEVER HALF HALF EAT how often do you prepare them in the microwave? OF THE OF THE OF THE THIS TIME TIME TIME FOOD

Beans, like green beans

Broccoli, cauliflower, cabbage

Greens, like spinach, kale, mustard greens, collards or chard

Potatoes

Summer squash and zucchini

Winter squash like acorn, spaghetti and butternut or pumpkin

Root vegetables like carrots, turnips, parsnips, kohlrabi

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PAGE 12 Cooking Practices (continued)

The following questions are about how meats or chicken are usually prepared. We realize people often cook by more than one method, but please choose only one response that represents what you do most often.

When you eat steak, how is it usually cooked? Don't eat steak Pan Fried Oven broiled Grilled or barbecued

When you eat steak how well Don't eat steak Medium rare Medium well done Very well done done is it usually cooked? Rare Medium Well done Charred

When you eat hamburger, how is it usually cooked? Don't eat hamburger Pan Fried Oven broiled Grilled or barbecued

When you eat hamburger, how Don't eat hamburger Medium rare Medium well done Very well done well done is it usually cooked? Rare Medium Well done Charred

Not counting fried chicken, when you Don't eat chicken Roasted or baked Grilled or barbecued eat chicken, how is it usually cooked? Only eat fried chicken Oven broiled Stewed or boiled

When you eat pork chops, how Don't eat pork chops Pan Fried Oven broiled are they usually cooked? Baked Grilled or barbecued

When you eat pork chops, how well Don't eat pork chops Just until done Very well done done are they usually cooked? Well done Charred

Please use a #2 pencil for this form

When you eat bacon or sausage, Don't eat bacon or sausage Well done or crisp how well done is it usually cooked? ReviewJust until doneCopy Charred How often do you eat meat, fish, or poultry that Never 1-2 times per week 1 time per day has been grilled or barbecued over coals, open 1 time per month or less 3-4 times per week 2 or more times fire, orDo ceramic briquettes? not use without2-3 times per month permission5-6 times per week per day

When you eat grilled or barbecued meat, Never grill or barbecue meat About half the time fish, or poultry, how often is it charred on Almost never or never charred Frequently charred the surface? Occasionally charred Almost always or always

When you eat pan-fried or oven-broiled Never fry or broil meat About half the time meat, how often is it well-browned on Almost never or never well-browned Frequently the surface? Occasionally well-browned Almost always or always

How often do you eat garlic or food prepared with Never 1-2 times per week 1 time per day garlic, either raw or cooked? DO NOT include 1 time per month or less 3-4 times per week 2 or more times garlic capsules or pills. 2-3 times per month 5-6 times per week per day

How often do you eat foods containing turmeric or Never 1-2 times per week 1 time per day cucurman, such as curries, rice and potato dishes or 1 time per month or less 3-4 times per week 2 or more times mustard? Please do not include turmeric capsules. 2-3 times per month 5-6 times per week per day

PAGE 13 Please use a #2 pencil for this form Mark here if you have Mark here a month in the past year a month in SERIAL # followed this diet for at least followed this NO PAGE) NEXT TO NO (GO year More than 1 more than 2 years 1 year 8 weeks - YES YES, currently 1-2 years Do you get indigestion or gas after you eat dairy Do you get indigestion or gas after products like milk, yogurt, or cheese? <8 weeks How long did you follow this diet? How long PAGE 14 PAGE YES, in the past followed less than 1 year For how long did you have this? PLEASE DO NOT WRITE IN THIS AREA NO 0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9 AGE

PLEASE MARK ALL THAT APPLY. APPLY. THAT ALL PLEASE MARK permission without use not Do

YES

Liquid/juice Vegetarian Low Salt Macrobiotic Diabetic diet Atkins Copy Sugar Busters Zone (Barry Sears) Review Watchers Joined a program like Weight to gain weight Tried High fiber Low fat Restricted Calories for longer than a month, other than during pregnancy? than a month, other for longer Which (if any) of these special diets have you ever diets have you any) of these special Which (if Some people follow special diets as part of their lifestyle. Others change their diet when there is a change in is a change there diet when their change Others lifestyle. of their as part diets follow special people Some weight. a goal like losing trying to achieve or when they are their life Have you ever had anorexia or bulimia? How old were you when you first had this? Has a health care professional ever told you that you are Has a health care professional ever products? lactose intolerant or allergic to dairy Special Diets Special Childhood Diet Think back to when you were about 10 years old, remembering where you lived, who lived with you, and who did the cooking. Think about the whole year and average out the number of times that you may have eaten a particular type of food. Answer each question as best you can. LESS ONCE MORE 2 or than than HOW OFTEN per EVERY MORE NEVER ONCE ONCE DAY TIMES WHEN YOU WERE 10 YEARS OLD per WEEK per per WEEK WEEK DAY

About how often did you eat "fast" foods like hamburgers, hot dogs, French fries, pizza, or tacos? About how often did you eat meat like beef, chicken, duck, lamb, or pork, including meat in mixed dishes like stew, meatloaf, or casseroles? About how often did you eat fish, seafood, or tuna including canned tuna? About how often did you eat processed meat like bacon, salami, hot dogs, bologna, or other luncheon meat?

About how often did you eat organ meats like liver, kidney, or brain? NOT including MILK, about how often did you have a serving of dairy products like cheese, yogurt or cottage cheese? (A serving is equal to about an ounce of cheese.) About how often did you eat a serving of fruit either canned, fresh, frozen, or as 100% juice? (A serving is equal to one medium apple or a half-cup of cut up fruit.) About how often did you eat a serving of vegetables either canned, fresh, frozen, or as 100% vegetable juice? Do NOT include potatoes or french fries but DO include salads, corn, green beans and other vegetables. (A serving is equal to about a half cup of cooked vegetables or a whole carrot.) About how often did you eat or drink soy milk, tofu, miso soup, or Chinese black

Please use a #2 pencil for this form bean sauce? About how often did you eat dried apricots, alfalfa sprouts, soybeans or sprouts, refried beans, or pinto beans? About how often did you eat garlic or food prepared with garlic, either raw or cooked? Please do NOT include Review garlic capsules. Copy About how often did you eat bread made with white flour such as white bread, biscuits, flour tortillas, and bagels? About how often did you eat cereal, either hot or cold, pancakes, waffles, or FrenchDo toast? not use without permission About how often did you eat rice, noodles, pasta (like macaroni or spaghetti), or potatoes cooked any way. Do NOT include sweet potatoes or yams. About how often did you eat sweets or desserts, including ice cream, candy, and pastries? About how often did you eat salty snacks like potato chips, crackers, pretzels, peanuts, or popcorn?

PAGE 15 Childhood Diet (continued)

Which fats or oils were usually used for cooking when you were 10 years old? (Mark all that apply.)

Margarine (stick or tub) Corn oil or vegetable oil Butter Canola oil Please use a #2 pencil for this form Crisco Oil spray like Pam Lard, fatback, bacon fat, or chicken fat Other kinds of oils like peanut or sesame oil Olive oil None of the above

Which fats were usually added after cooking to vegetables, potatoes or at the table when you were 10 years old? (Mark all that apply.)

Margarine (stick or tub) Corn oil or vegetable oil Butter Canola oil Crisco Oil spray like Pam Lard, fatback, bacon fat, or chicken fat Other kinds of oils like peanut or sesame oil Olive oil None of the above

About how often did you have a glass of milk when you were 10 years old? Never 2-3/day Several times a week 4-5/day 1/day 6 or more/day

How old were you when you Please think back to the years before you turned 21. How long did you follow this diet? Which (if any) of these diets did you follow for longer first followed this diet? than a month? 8 weeks - More than 1 10 – 15 16 – 21 PLEASE MARK ALL THAT APPLY. <8 weeks 1 year year <10 years years years

Part-Vegetarian or Semi-Vegetarian -- eating no red or white meat (beef, pork, venison, etc.), but sometimes eating poultry and fish, or fats, oils, gelatin and other Reviewproducts that come Copy from animals.

Ovo-LactoDo Vegetarian not use without permission -- eating eggs and dairy products and maybe meat by-products (e.g. fats, gelatin) but no meat or flesh of any kind.

Vegan Vegans are strict vegetarians. They eat only plant foods - no animal products, no eggs, no dairy, no honey. Macrobiotic Vegetarian -- eating no meat, poultry, dairy products, or eggs, but sometimes eating fish.

Did you use the pictures to choose your serving size on this form? Yes No I didn't have any pictures.

Thank you very much for filling out this questionnaire.

PLEASE DO NOT WRITE IN THIS AREA SERIAL #

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