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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.)


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