Sample Questionnaire
Return to CHARRED home
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
a. Hamburgers or
cheeseburgers
(including fast food) |
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1 medium
or 4 oz. |
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Pan fried |
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Grilled or Barbecued |
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Oven-broiled |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
b. Beef Steaks |
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4 oz. |
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Pan fried |
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Grilled or Barbecued |
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Oven-broiled |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
c. Pork chops or ham steaks |
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2 chops or
or 4 oz. |
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Pan fried |
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Oven-broiled |
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Baked or Roasted |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
d. Bacon |
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2 strips |
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Pan fried |
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Oven-broiled |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
e. Breakfast sausage |
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2 links or 2 patties |
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Pan fried |
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Grilled or Barbecued |
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Oven-broiled |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
f. Fried chicken |
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2 small or 1 large piece |
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Deep-fat fried or fast food |
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Pan fried |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
g. Chicken or turkey, including sandwiches |
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2 small or 1 large piece |
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Baked or Roasted |
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Stewed |
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Oven-broiled |
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Grilled or Barbecued |
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Cooked another way
(SPECIFY)
_______________ |
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Never |
Less
Than
Once
Per
Month |
1
Per
Mo. |
2-3
Per
Mo. |
1
Per
Wk. |
2-3
Per
Wk. |
3-4
Per
Wk. |
5-6
Per
Wk. |
1
Per
Day |
2+
Per
Day |
Medium Serving |
Size |
S |
M |
L |
h. Gravy |
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2 tbsp |
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Made from meat drippings |
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Store-bought cans |
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Store-bought packets |
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Made another way
(SPECIFY)
_______________ |
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A hamburger or cheeseburger |
Rare |
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Medium-rare |
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Medium |
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Medium-well |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Steak |
Rare |
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Medium-rare |
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Medium |
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Medium-well |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Pork chop or ham steak |
Just until done |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Bacon |
Just until done |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Breakfast sausage |
Just until done |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Fried chicken |
Just until done |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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Chicken |
Just until done |
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Well-done |
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Very well-done |
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Don't know |
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Did not eat |
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