Questionnaire Research Depend Nutrition - Outline Example

1 Women Diet and Exercise Instructions: We would like to thank you for agreeing to participate in this survey. Please understand that you need not place your name or any other self identifying marks on your questionnaire. It is our intent for you to remain unanimous, However, it is our endeavor to solicit from you, the most candid responses possible. The questions are simple and straightforward and are all relevant to your perceived and actual ideas about diet, nutrition and weight loss. Again, thank you for participating. (1) Which one of the following best describes the way you feel about your overall appearance? (a) [ ] in good shape, (b) [ ] moderately overweight, (c) [ ] seriously overweight, (d) [ ] slightly underweight, (e) [ ] moderately overweight (f) [ ] seriously underweight. (2) If you were presented with the opportunity to change any part of your body, which part would you change? ______________________________,__________________. (3) What is your height,________, Weight___________. (4)How would you rate your looks? (a) [ ] very attractive, (b) [ ] moderately attractive © [ ] average looking. (5)Are you currently involved with any type of diet? (a) [ ] Yes, (b) [ ] No. (If yes, and your diet has a specific name, please list it,___________________________. Also, if yes, please answer #5(a), if no, please proceed to #6). (5a) Please describe your diet menu for each meal Breakfast__________,_______________,_____________,____________,_______ Snack____________,___________,______________,________________,_______ 2 Lunch__________,___________,______________,_____________,____________ Snack__________,____________,____________,_____________,_____________ Dinner_________,____________,______________,___________,______________ 6. How would you rate your diet, would you say it is ( answer all that apply) (a) [ ] low is saturated fats & cholesterol, (b) [ ] high is saturated fats & cholesterol © [ ] moderate in saturated fats & cholesterol, (d) [ ] low in grain products, (e) [ ] high in grain products, (f) [ ] moderate in grain products, (g) [ ] low in variety (h) [ ] high in variety, (i) [ ] moderate in variety, (j) [ ] low in salt & sodium (k) [ ] high in salt & sodium, (l) [ ] moderate in salt & sodium, (m) [ ] low in sugar (n) [ ] high in sugar, (o) [ ] moderate in sugar. 7. Do you take any vitamin supplements? (a) [ ] Yes, (b) [ ] No. If yes, please answer nos. 7a thru #8, if no, proceed to #9. 7a. If yes, which supplements do you take,(1)______________(2),_________(3),_____ ____________,(4)_________(5)_______How frequently do you take……… (1)____________, how long have you been taking______(a) 0-6 mos. , (b) 1 yr or more (2)____________, how long have you been taking______(a) 0-6 mos., (b) 1 yr or more (3)____________, how long have you been taking______(a) 0-6 mos., (b) 1 yr or more (4)____________, how long have you been taking______(a) 0-6 mos., (b) 1 yr or more (5)____________, how long have you been taking______(a) 0-6 mos., (b) 1 yr or more 8. Who recommended that you should take vitamin supplements? (a) [ ] physician (b) [ ] dietician, (c)[ ] personal trainer, (d) [ ] relative, (e) [ ] personal friend, 9. If you had to place a monetary figure on the cost of your dietary, or weight loss program, what would it be? (a) [ ] 100 – 200 per year, (b) [ ] 300 – 400 per year, (c) [ ] 400-700 per year, (d) [ ] more than 1,200 per year. 10. Do you consume alcoholic beverages? (a) [ ] Yes, (b) [ ] No. ( If yes, proceed to ques. 10.a and # 11. If your response is no, then proceed to ques. #11). 10.a If yes, how frequently? (a) [ ] everyday, (b) [ ] once a week, (c) [ ] more than three times a week. in any given sitting, how many drinks do you generally consume? 3 (aa) [ ] one, (bb) [ ] two, (cc) [ ] more than three. What is your drink of choice.______________.. 11.Do you smoke cigarettes? 9 [ ] Yes, (b) [ ] No. (If yes, proceed to ques # 11a, and 11b if no, then proceed to #12) 11.a If yes, How many sticks per day, do you smoke? (a) [ ] 1-3, (b) [ ] 4 – 6, (c) [ ] 7- 10 (d) [ ] 8 – 12, (e) [ ] 13 – 15, (f) [ ] 16 -19, (g) [ ] 20 or more. 11.b. How would you classify your smoking habit? (a) [ ] out of control, (b) [ ] can regulate consumption levels, (c)[ ] light 12. What women magazines do you read, at least once per month?__________,________ _____________,_____________, (if none, then proceed to ques # 15) 13.Considering the magazines which you do read, what is your impression of the body images of the female models? (a) [ ] very favorable, (b) [ ] moderately favorable, © [ ] very unfavorable, (d) [ ] moderately unfavorable. 14.You considered the body images of the models to be___________________, on a scale of 1 to 10, with 1 being the lowest and 10 being the highest, how would you rate their body types as being your ideal?________. 15. What part of your body do you consider to be your most positive feature? (only pick one) (a) [ ] face, (b) [ ] breast, (c) [ ] abdomen, (d) [ ] hips, (e) [ ] thighs, (f) [ ] feet 15.a Which part of your body do you consider to be your most negative feature? (list one)______________________. 16.If presented with the opportunity to change any part of your body, which would it be? __________________________,_____________________ 4 17. Do you consider yourself to be in good health? (a) [ ] Yes, (b) [ ] No 18.Are you currently involved in any exercise routine? (a) [ ] Yes, (b) [ ] No. ( If yes, continue with #17a, if your response is “No” then proceed to ques. #26) 18.a If yes, what is the nature of your routine? (a) [ ] running, (b) [ ] swimming, (c)[ ] aerobics, (d) [ ] dance-er size, (e) [ ] gym membership (f) [ ] commercial plan (Jenny Craig etc.) 19. How often do you participate in your routine? (a) [ ] 1 – 3 times per day, (b) [ ] 1 – 3 times per week, (c) [ ] once per week, (d) [ ] once a month. 20.How much time do you devote to your routine when you participate? (a) 30 min. or less, (b) [ ] 1 – 2 hours, (c) [ ] 3 – 4 hours. 21. Do you exercise alone or do you have a companion? (a) [ ] alone, (b) [ ] companion. 22. What time of day do you consider to be your ideal time to work out? (a) early morning, (b) [ ] late morning, after 10am before noon, (c) [ ] afternoon, (d) [ ] evening 23. During the days and time when you work out, when do you eat? (a) [ ] before, (b) after, (c) [ ] other, explain ________________________________________________ 24.What type of drink do you consume for hydration, when working out? (a) [ ] tap water, (b) [ ] bottled water, (c) [ ] athletic fruit drink, (d) [ ] health supplement 24.a What would you say is your favorite drink of choice?_______________, would you say it best serves you for …(a) [ ] hydration, (b) [ ] energy, (c) [ ] both. 25. Have you ever been hospitalized for a failing health condition? (a) [ ] Yes, (b) [ ] No If the response was yes, then answer 25.a. If the response was no, then proceed to #26). 5 25.a State the reason for your confinement._________________________,___________. 26.Would you say that your blood pressure is..(a)[ ] high, (b) [ ] normal, (c) [ ] low 27. Do you or any member of your nuclear family suffer from any of the following: (a) [ ] high blood, (d) [ ] diabetes, (c) [ ] arthritis (If yes, who)________,_______ 28. Would you say your cholesterol is..(a) [ ] high, (b) [ ] normal, (c) [ ] low. 29. Would you say your blood sugar is…(a) [ ] high, (b) [ ] normal, (c) [ ] low. This concludes our interview, I would only like to ask you afew questions for classification purposes: What is your age, is it [ ] 18 – 25 [ ] 26 -35 [ ] 36 – 43 [ ] 44- 50 How many persons reside in your household? [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 or more In your household, how many children are under the age of 18 years of age? [ ] 1 – 3 [ ] 4 – 7 6 What is your status in the household? [ ] head of household [ ] spouse [ ] resident off spring [ ] employee What is your educational attainment level [ ] high school graduate [ ] college or university graduate [ ] post graduate (master, Ph.D. etc.) [ ] professional degree (lawyer, physician) What is your occupation? ____________________________________. What is your annual income? [ ] below 20,000 [ ] 25,000 – 40,000 [ ] 45,000 – 60,000 [ ] 65,000 – 80,000 [ ] 85,000 – 100,000 [ ] 125,000 – above This concludes our questionnaire, and we thank you very much for your time and cooperation. Read More