Name Date Entry Exit Adult Questionnaire 1. How many times a day do you eat fruit? Examples of fruits are apples, bananas, oranges, grapes, raisins, melon and berries, Include fresh frozen, dried, or canned fruit. Do not include juice. I rarely eat fruit Less than 1 time a day (a couple times a week) 1 time a day 2 times a day 3 times a day 4 or more times a day 2. How many times a day do you eat vegetables? Examples of vegetables are green salad, corn, green beans, carrots, potatoes, greens, and squash. Include fresh, canned, and frozen vegetables. Do not count french fries, potatoe chips, or rice. I rarely eat vegetables Less than 1 time a day (a couple times a week) 1 time a day 2 times a day 3 times a day 4 or more times a day 3. How many different kinds of vegetables do you usually eat aday? I rarely eat vegetables Less than 1 time a day (a couple times a week) 1 time a day 2 times a day 3 times a day 4 or more times a day 4. How many times a day do you drink milk or soymilk? Do not count almond or coconut milk, or milk with cereal. I do not drink milk I rarely drink milk 1 time a day 2 times a day 3 or more times a day 5. Over the last week, how many days did you eat red and ornage vegetables? Examples of red or orange vegetables are tomatoes, red peppers, carrots, sweet potatoes, winter squash, and pumpkin. I did not eat red or orange vegetables 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 6. Over the last week, how many days did you eat dark green vegetables? Examples of dark green vegetables are broccoli, spinach, dark green lettuce, turnip greens, or mustard greens. I did not eat green vegetables 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 7. Over the last week, how many days did you eat beans and peas? Examples of beans and peas include pinto beans, black beans, navy beans, chili beans, refried beans, pork and beans, bean soup, barbeque beans, chickpeas, split peas, and black eyed peas. Include beans from a can or cooked from dry. I did not eat beans and peas 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 8. Over the last week, how many days did you eat yogurt or drink smoothies with yogurt? I did not eat yogurt 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 9. Over the last week, how many days did you eat cereal with milk? I did not eat cereal with milk 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 10. How many days a week do you cook dinner (your main meal) at home? I rarely cook dinner at home 1 day a week 2 days a week 3 days a week 4 days a week 5 days a week 6-7 days a week 11. How often do you drink regular sodas (not diet)? Never 1-3 times a week 4-6 times a week 1 time a day 2 times a day 3 times a day 4 or more times a day 12. In the past week, how many days did you exercise for at least 30 minutes? This includes things like jogging, playing soccer, and doing fitness or dance classes, or exercise videos. This 30 minutes could be all at once or a few minutes at a time. Do not count housework, taking care of your kids, or walking from place to place. 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 13. In the past week, how many days did you do workouts to build and strengthen your muscles? This includes things like lifting weights and doing push-ups, sit-ups, or planks. 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 14. How often do you make small changes on purpose to be more active? This includes things like walking instead of driving, getting off the bus one stop early, doing a few minutes of exercise, or moving around instead of sitting while watching TV. Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 15. How often do you wash your hands with soap and running water before preparing food? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 16. After cutting raw meat or seafood, how often do you wash all items and surfaces that came in contact with these foods? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 17. How often do you thaw frozen food on the counter or in the sink at room temperature? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 18. How often do you use a meat thermometer to see if meat is cooked to a safe temperature? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 19. How often do you compare food prices to save money? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 20. How often do you plan your meals before you shop for groceries? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 21. How often do you look in the refrigerator or cupboard to see what you need before you go shopping? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 22. How often do you make a list before going shopping? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 23. How often do you use food coupons for food purchases? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 24. How often do you use a written weekly or monthly food spending plan? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 25. How often do you budget enough money for food purchases? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 26. How often do you check for sales on foods before you shop? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always 27. How often do you check for food items on sale when you are at the store? Never Rarely (about 20% of the time) Sometimes (about 40% of the time) Often (about 60% of the time) Usually (about 80% of the time) Always The next section has statements people have made about their food situation. Choose the answer that best fits your food situation over the last 30 days. 28. The food that I bought just didn’t last, and I didn’t have money to get more. Often true Sometimes true Never true Don’t know 29. I couldn’t afford to eat balanced meals. Often true Sometimes true Never true Don’t know 30. Did you ever cut the size of your meals or skip meals because there wasn’t enough money for food? Yes No Don’t know This material is based upon work that is supported by the National Institute of Food and Agriculture, US Department of Agriculture. USDA is an equal opportunity provider, employer, and lender. May 2020