Fruit, Vegetable and Fiber Screener

Your Name (optional):
Age:
Sex: Male Female

Think about your eating habits over the past year or so. About how often do you eat each of the following foods? Remember breakfast, lunch, dinner, snacks and eating out. Check one radio button for each food.

Fruits, Vegetables,
and Grains
 Less than
1/WEEK		 Once a
WEEK		 2-3 times a
WEEK		 4-6 times a
WEEK		 Once a
DAY		 2+ a
DAY
Fruit juice, like orange, apple, grape, fresh, frozen or canned. (Not sodas or other drinks)
How often do you eat any fruit, fresh or canned (not counting juice?)
Vegetable juice, like tomato juice, V-8, carrot
Green salad
Potatoes, any kind, including baked, mashed or french fried
Vegetable soup, or stew with vegetables
Any other vegetables, including string beans, peas, corn, broccoli or any other kind
Fiber cereals like Raisin Bran, Shredded Wheat or Fruit-n-Fiber
Less than
1/WEEK		 Once a
WEEK		 2-3 times a
WEEK		 4-6 times a
WEEK		 Once a
DAY		 2+ a
DAY
Beans such as baked beans, pinto, kidney, or lentils (not green beans)
Dark bread such as whole wheat or rye