1. Gender [you may ask this, or you may simply observe and record the answer]
2. Do you or does someone in your household grow any of your own food to eat? Choose one of these:
Yes –fruit; Yes – veggies; Yes – fruit and veggies;
Yes –something else; No
[if someone grows fruit, veggies & something else, just answer Yes-fruit & veggies]
3. What do you think of this statement: “It has been proven that when kids eat sugar it typically leads them to be hyperactive?”
Choices are: Strongly agree; Agree; Don’t know; Disagree; Strongly disagree
4. From this list of choices, which is your favorite type of movie to watch? You must choose only one even if there are several you like. Choices:
Action, Comedy, Documentary, Drama, Horror, Musical, Romance, Thriller, Other type, Don’t like movies
[ if someone asks, explain that the movie could be watched in a theater or at home, DVD or streaming – it doesn’t’ matter]
5. From this list of choices, which is your favorite restaurant cuisine? You must choose only one even if there are several you like. Choices:
American, Asian, European, Italian, Mexican, Middle-eastern, Other
6. Age (in whole number of years)
7. What is the number of computers in the household that you are living in now? Do count laptops, desktops, & tablets. Do not count phones. The computers don’t have to be yours, but they “live” in your household.
8. In a typical week, what is the number of times you eat a meal out (breakfast, lunch, and/or supper) in a restaurant, cafeteria, café, coffee-shop – any type of establishment that sells food to eat there?
9. What is the number of drinks of coffee you have in a typical week? (include: lattes, mochas, any kind of coffee drink, caffeine or decaf, hot or cold)
10. What is the number of drinks of tea you have in a typical week? (include: hot tea, cold tea, with or without caffeine, herbal, black, green, any color)
11. In a typical week, what is the number of times you cook a meal? By “cook a meal” we mean doing something more than heating a pre-cooked meal or pouring a bowl of cereal.
12. Typically, how many times a week do you exercise or work-out for at least 20 minutes (any somewhat vigorous exercise counts such as running, playing a sport, going to the gym, brisk walking, swimming, riding a bike, yoga, martial-arts, etc.)