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23
Questions
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1
Name
First Name
Last Name
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2
Gender
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3
Age
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4
Height
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5
Weight
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6
How many meals do you eat away from home on weekdays?
How many
Breakfasts
Row 0, Column 0
Lunches
Row 1, Column 0
Dinners
Row 2, Column 0
Breakfasts
Lunches
Dinners
How many
Row 0, Column 0
How many
Row 1, Column 0
How many
Row 2, Column 0
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7
How many meals do you eat away from home on weekends?
How many
Breakfasts
Row 0, Column 0
Lunches
Row 1, Column 0
Dinners
Row 2, Column 0
Breakfasts
Lunches
Dinners
How many
Row 0, Column 0
How many
Row 1, Column 0
How many
Row 2, Column 0
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of 3
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8
Please indicate your meal time of the last 3 days
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9
How often do you eat hot meals?
None
1-3 times per week
3-5 time per week
Once a day
Several times a day
During weekdays
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
During weekends
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Responsiveness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Friendliness
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
During weekdays
During weekends
Responsiveness
Friendliness
None
Row 0, Column 0
1-3 times per week
Row 0, Column 1
3-5 time per week
Row 0, Column 2
Once a day
Row 0, Column 3
Several times a day
Row 0, Column 4
None
Row 1, Column 0
1-3 times per week
Row 1, Column 1
3-5 time per week
Row 1, Column 2
Once a day
Row 1, Column 3
Several times a day
Row 1, Column 4
None
Row 2, Column 0
1-3 times per week
Row 2, Column 1
3-5 time per week
Row 2, Column 2
Once a day
Row 2, Column 3
Several times a day
Row 2, Column 4
None
Row 3, Column 0
1-3 times per week
Row 3, Column 1
3-5 time per week
Row 3, Column 2
Once a day
Row 3, Column 3
Several times a day
Row 3, Column 4
1
of 4
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10
Do you eat at nights?
Yes
No
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11
How much coffee/ tea do you drink a day?
None
1-2 cups per day
3-4 cups per day
5-6 cups per day
More than 4 cups
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12
How many alcoholic drinks do you have in a week where a standard drink is one of 1dL of wine, 3dL of beer, 2 cL of liquors?
None
1-3 standard drinks a week
4-7 standard drinks a week
8-12 standard drinks a week
More than 12 standard drinks a week
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13
How often do you eat in a restaurant?
None
1-2 times per week
3-4 times per week
5-6 times per week
More than 7 times per week
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14
Do you watch out to eat healthy?
Yes
No
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15
What type of food do you buy?
Fresh foods
Pre-cooked foods
Canned foods
Frozen foods
Other
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16
What do you do for living?
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17
How many hours do you approximately seat in a day?
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18
How many hours do you approximately stand in a day?
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19
How many hours do you approximately walk in a day?
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20
How many hours do you approximately run in a day?
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21
How many hours do you approximately rest in a day?
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22
How many hours do you approximately sleep in a day?
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23
Any comments that you would like to add
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