Lifestyle questionnaire - IRCM

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1 - Eating habits sectionHere is a list of questions that is intended to evaluate your lifestyle.For each of them, circle the answer that best reflects your current lifestyle:DO YOUR FOOD CHOICES POSE A CARDIOVASCULAR RISK?Quick question to assess healthy eatingHAVE YOU EVER SEEN A DIETICIAN BEFORE? Yes (Year_________) NoARE YOU CURRENTLY ON ANY PARTICULAR DIET? Yes NoIf so, what diet? ______________________________________________________________________________________________QUESTIONS A B C TOOLSHow many meals do you eat a day? 3 meals per day I often eat a fourthmealDo you eat between meals?How often do you eat out?(sandwiches, fast food, pizza, barbecue, Chinese food…)Do you eat prepared foods?(frozen foods, pizza, Italian or Chinese food, packaged rice andpasta sides…)How many vegetables do you eat?1 portion = 1 average vegetable, ½ cup fresh, frozen or cannedvegetables, 1 cup lettuce, ½ cup vegetable juiceHow much fruit do you eat?1 portion = 1 average fruit, ½ cup fresh, frozen, canned or pureedfruit, ½ cup fruit juiceHow big is your meat portion per meal?1 portion = 100 g or 3 ounces or the equivalent of a deck of 52cardsNo / I have a snackwhen I need itLess than once aweekI generally eatduring the eveningOnce or twice aweek< once a week once or twiceweek1-2 meals per day 1I often nibblebetween mealsThree meals perweek or more> 3 times a week 41, 2, 18> 4 per day 2 or 3 per day ≤ 1 per day 6 - GAC> 3 per day 2 per day ≤ 1 per day 6 - GAC1 deck of cards orlessBetween 1 and 2decks of cards2 decks of cardsor moreDo you eat chicken skin or visible fat on meat? Never Sometimes Always 5, 13Do you eat deli meat or fatty meat?(bacon, sausages, baloney, salami, pepperoni, liver pâté, cretons,chicken wings, patties, ribs, ground meat)Less than once aweekonce or twice aweek3 or more times aweekDo you eat unbreaded fish? ≥ twice a week Once a week Rarely 7Do you eat cheese?1 portion = 30 g or 1 ounce, sliced cheese (1-2), cream cheese(30 ml or 2 tablespoons). Do not count skim milk cheese or cottagecheese.3, 45, 16 - GAC4, 5, 16≤ twice a week 3-4 times a week ≥ 5 times a week 5, 8, 16What kinds of dairy products (milk and yogurt) do you eat? Less than 2% b.f. 2% b.f. > 3% b.f. / I don’teat any5, 8 - GACWhat kinds of fats do you usually use?(for cooking, as a spread, potatoes, sauces...)*NH: non-hydrogenatedWhat percentage of your plate is filled by grain or starches?(pasta, rice, couscous, potatoes…)Do you select whole grain products?(whole grain bread, high-fibre breakfast cereals, brown rice…)How often do you eat baked products?(doughnuts, buns, croissants, danish pastries, muffins). Do notcount homemade muffins.How often do you eat store-bought desserts?(as a snack or after a meal: chewy bars, cookies, regular icecream, cakes, pastries, pies, etc.)How often do you eat sweets?(candies, chocolate, table sugar, honey, jam…)Do you drink sweet drinks?(fruit juice or fruit drinks, soft drinks or energizing drinks, iced tea,lemonade…)Vegetable oil ormargarine *NHOil, margarine orbutterButter, cream, lard,shortening, regularmargarine1/4 of the plate ½ of the plate More than ½ of theplate5, 101 - GACYes, always Sometimes Rarely 12 - GAConce a week or less 2 -3 times a week 4 times a week ormoretwice a week or less 3-4 times a week 5 times a week ormore3 times a week orless4-5 times a week Every day 98 oz or less per day 8-16 oz per day 16 oz or more perday5, 139, 13, 149, 15
1 - Eating habits sectionHere is a list of questions that is intended to evaluate your lifestyle.For each of them, circle the answer that best reflects your current lifestyle:What is your average alcohol consumption?1 drink = 5 oz of wine, 1 beer, 1½ oz of spiritsDo you eat soups, broth or sauces, in pouches or canned?Do you eat salted foods?(crackers, chips, popcorn, pretzels, salted nuts or seeds, etc.)A B C TOOLS1 per day 2 per day more than 2 perdayless than once aweekless than once aweekonce or twice aweekDo you add salt to your food? Rarely Often / with certainfoodsDo you read the nutrition facts table on food labels?Do you want to lose weight?BMI =___________________ Normal weight Overweight ObesityYes, and I understandthe informationmore than 3 timesa week2-3 times a week more than 4 timesa weekOften, but I findit difficult tounderstand174, 114, 10, 18Usually 4, 11Rarely 14OUI NON 15< Less than > More than< Less than or equal to > More than or equal toDO YOU TRY TO EAT A HEALTHY BALANCED DIET EVERY DAY?A. YES, for over 6 months MaintenanceB. YES, for less than 6 months ActionC. NO, but I plan to start doing so within the next 60 days PreparationD. NO, but I plan to within the next 6 months ContemplationE. NO, and I do NOT plan to within the next 6 months Precontemplation
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Lifestyle questionnaire - IRCM

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