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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