| 1. | Do you eat cheese everyday? | Yes | No | ||
| 2. | What kind of milk do you normally use? | Home | 2%, 1% or skim | ||
| 3. | Do you always use butter or margarine on your bread? | Yes | No | ||
| 4. | How often do you go out for fast food? | Once a week or more | Occasionally | ||
| 5. | How much meat, poultry, or fish do you like to eat at meals? | A lot | Just a small piece | ||
| 6. | Do you always have some kind of meat, poultry, or fish for dinner? | Yes | No | ||
| 7. | Do you usually use deli or luncheon meats in sandwiches? | Yes | No | ||
| 8. | How often do you give in to your sweet tooth for cookies, cakes, donuts or squares? | Everyday | Once in a while | ||
| 9. | What bread do you use for sandwiches and toast? | White | Whole wheat or other whole grain | ||
| 10. | What kind of cereal do you usually eat? | Regular types like corn flakes | Whole grain, bran, or high fibre | ||
| 11. | How many fruits and vegetables would you eat in a day? | 2 or 3 | 4 or more | ||
| 12. | How often do you eat broccoli, brussels sprouts, cabbage or turnip? | About once a week | Several times a week or more | ||
| 13. | How often do you eat carrots, squash, spinach, cantaloupe, mangoes, and papayas? | About once a week | Several times a week or more | ||
| 14. | Are you way over the weight that you should be? | Yes | No | ||
| 15. | Do you have more than two alcoholic drinks a day? | Yes | No |
Enter the number of selections made in the second column

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