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FOOD RECALL
Instruction: Recall 24 hour food intake during an RLE day, ordinary school day and a weekend. Please
specify the day and date on the blank provided.
Breakfast
Snack
Lunch
Snacks
Supper
Midnight Snack
Snack
Lunch
Snacks
Supper
Midnight Snack
Breakfast
Snack
Lunch
Snacks
Supper
Midnight Snack
B: Eating Habits
Instruction: Please put a (/) check mark on the box, or encircle the letter corresponding to your answer.
1. What meals do you usually skip most? ❐Breakfast ❐Lunch ❐Dinner ❐NONE
2. How many glasses of water do you consume in a day?
3. Do you drink coffee? ❐ No ❐ Yes? (How many cup of coffee do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
5. Do you put milk or creamer in the coffee? ❐ No ❐ Yes (How many?) ______________
a. 1 teaspoon
b. 1 tablespoon
c. 1 ½ tablespoon
d. Or more
6. Do you drink juice? ❐ No ❐ Yes? (How many glass of juice do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
7. Do you drink milk? ❐ No ❐ Yes? (How many cup of milk do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
8. Do you drink tea? ❐ No ❐ Yes? (How many cup of tea do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
9. Do you drink soda? ❐ No ❐Yes (how many bottle/can of soda each day?) ______________
a. One bottle/can
b. 2-4 bottles/can
c. 4-6 bottles/can
d. Or more
A. one bread
B. 2-4 bread
C. 5-10 bread
D. Or more
12. Do you routinely use butter or bread products such as toast, bagels, etc.
❐ No ❐Yes (how many times?)
a. Once a day
b. 2-3 times a day
13. How often do you eat meat per week?c. 4-6 times a day
d. Or more
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
21. Do you consume citrus fruits? ❐ Yes ❐ No
How often? ____________________
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
22. How many servings of fruits?
❐1 serving
❐2-4 servings
❐5-10 servings
❐or more
23. Do you routinely use butter for cooking or on baked potatoes or vegetables?
❐ No ❐ Yes (how many times?)
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
28. How often, on average, do you consume any sugary carbohydrate snacks and drinks (e.g.,
regular soft drinks, licorice, jujubes, hard candies, gummy bears, etc.?)