Determine If Eating Meals Prepared at Restaurants is Correlated with Increased Weight
1. Gender: o Female o Male
2. Age :________
3. Ethnicity: o Caucasian
o Hispanic
o African American
o Asian American o Native Central or South American o Other_____________________________
4. Highest completed level of education:
o Elementary, Middle School
o High School
o College
o Graduate School
o Post-Graduate School
5. How would you describe the area you live in?
o Rural
o Suburban
o Urban
6. What kinds of transportation do you have access to? (check all that apply)
o Car
o Subway
o Bus
o Train
o I can walk many places
7. Height _______feet ________inches or _________cm
8. Weight _______lbs. or _________kg
9. Do you have any current health concerns regarding disease or weight (please specify):_____________________________________________________________
10. Are you currently on any medications (please specify):_____________________
____________________________________________________________________
11. Has your weight changed in the past five years? o Yes o No
If yes, how has it changes?
o Gain >10lbs
o Gain 5-10lbs
o Stayed same
o Lost 5-10lbs
o Lost >10lbs
12. How many times a week did you eat food prepared at restaurants before the age
of 18? ___________times
13. How many times a week do you currently eat food prepared at restaurants? __________times
14. When you eat foods prepared at restaurants, how much of the food on the plate do you eat?
o < ¼
o 1/3
o ½
o ¾
o All of it
15. When you eat food prepared at a restaurant how often do you order appetizers?
o Never
o Seldom
o Sometimes
o Usually
o Always
16. How often do you eat vegetables (excluding potatoes) with meals prepared at restaurants?
o Never
o Seldom
o Sometimes
o Usually
o Always
17. How often do you order dessert at restaurants?
o Never
o Seldom
o Sometimes
o Usually
o Always
18. When you eat at restaurants or get take-out what type of food do you usually get? (check all that apply)
o Sandwiches o Chinese
o Japanese o Thai
o Indian o Italian
o Mexican o Salads
o Soup o Pizza
o Fried foods
19. What kinds of restaurants do you go to? (check all that apply)
o Fast Food
o Food Cafeteria
o Food Cart/Stand
o Sit Down
o Bar/Tavern
o Fine Dining
20. Do you drink alcohol with your meals? o Yes o No
21. How many alcoholic beverages do you drink a week? _____________drinks a week
22. Do you drink soft drinks or juice with your meals? o Yes o No
23. How many soft drinks or juice beverages do you drink a week?
_________drinks a week
24. How many times a week do you cook breakfast at home? ______times
25. How many times a week do you cook lunch at home? ______times
26. How many times a week do you cook dinner at home? _____times
27. Of these options, what do you consider a home cooked meal? (check all that apply)
o Microwaving a frozen entrée
o Boiling pasta with sauce from a jar
o Preparing a boxed meal (such as macaroni and cheese)
o Grilling/baking fish, chicken, etc with vegetables and/or rice
o Heating up canned soup
28. When you cook at home do you (check all that apply):
o Fry o Bake
o Grill o Broil
o Boil o Roast
o Saute o Steam
29. When you cook how often do you prepare vegetables (not including potatoes)?
o Never
o Seldom
o Sometimes
o Usually
o Always
30. When you cook do you use oil or butter? o Yes o No
If so, how often?
o Never
o Seldom
o Sometimes
o Usually
o Always
31. If you use butter or oil when cooking how much do you usually use?
o 1 teaspoon or less
o 2-4 teaspoons
o 2-3 tablespoons
o ≥ 4 tablespoon
32. When you cook how often do you eat dessert?
o Never
o Seldom
o Sometimes
o Usually
o Always
33. What time of day are you more likely to go to restaurants or get take-out (check all that apply):
o Morning/breakfast
o Midmorning
o Lunch
o Midafternoon
o Evening
o Late evening
o Late night
34. How do you usually feel when you are eating? (check all that apply)
o Rushed
o Stressed
o Calm
o Sad
o Happy
o Angry
35. How many hours a week do you work? _______hours
Thank You For Your Time!