QUESTIONNAIRE.

LOCATION OF THE PLACE

Sub county…………………………….
Location……………………………….
Village…………………………………

PART A: SOCIAL AND DEMOGRAPHIC

Sex: 1= Male 2= Female
Which age bracket do you fall in?
1= 65-75 2=75-85 3= 85 and above 4= Uncertain
Who do you stay with at home?
1= relatives 2= neighbor 3= other
PART B: DIET HISTORY AND DIETARY PRACTICES.
1. Please describe what you usually eat and drink for breakfast on weekdays…………..
2. Please describe what you usually eat and drink for breakfast on weekends……........
3. Please describe what you usually eat and drink for lunch on weekdays……………..
4. Please describe what you usually eat and drink for lunch on weekdays…………….
5. Please describe what you usually eat and drink for dinner on weekdays…………..
6. Please describe what you usually eat and drink for dinner on weekdays…………..
7. At what time do you eat dinner on weekends?
1= before 6pm 2=6-8pm 3=8-10pm 4= don’t eat dinner
8. What time do you usually go to bed?
1= 8-9.59 pm 2= 10-11.59pm 3= 12 am or later.
9. Do you usually eat a snack (any food or drink between meals times) between lunch and dinner
on weekends? ............................................
10. How do you describe your appetite?
1= Good
2= Fair
3= Poor
11. Do you usually drink alcohol?
1= Never: Never
2= rarely: 2-3 times a month
3= sometimes: once a week
4= often: 2-3 times a week
5= Always: Daily

12. Are you happy with your weight?

1= YES 2= NO
13. Has your weight changed in the past year?
1= No
2= Gained
3= Lost
14. If yes, by how much has your weight changed?
1= +1kg
2= +2kg
3= +2kg to 5kg
4= +5kg to 10kg or more
5= -1kg
6= -2kg
7= -2kg to 5kg
8= -5kg to 10kg or more
9= unsure.
15. Please give answer for how often you usually practice the following behaviors.
Please tick one box per line
a) Reading food labels when deciding what to eat?
1= Never and Rarely 2= Sometimes 3= Often and always
1. Eat sweets (e.g. chocolate. Cakes, biscuits, ice cream )
1= Never and Rarely 2= Sometimes 3= Often and always
b) Drink commercial beverages (e.g. Coca-Cola soda, Pepsi, novida, energy drinks, )
1= Never and Rarely 2= Sometimes 3= Often and always
c) Eat meals without meat. (A vegetarian diet)?
1= Never and Rarely 2= Sometimes 3= Often and always
d) Eat fried foods (e.g. fried chicken, dried fish)?
1= Never and Rarely 2= Sometimes 3= Often and always
e) Remove the skin from chicken?
Never and Rarely 2= Sometimes 3= Often and always
f) Trim (cut away) fat from meat?
1= Never and Rarely 2= Sometimes 3= Often and always
g) Eat until you are stuffed.(extremely full)
1= Never and Rarely 2= Sometimes 3= Often and always

16. What type of fat do you prefer to use in cooking?

1= Saturated (solid) 2= Polyunsaturated (Liquid) 3= Uncertain
17. How many glasses of milk do you drink each day?
1= glass or more
2= less than one glass
18. How often do you eat fruit or drink a glass of juice?
1= at least 3 times a week?
2= less than 3 times a week
PART C: HEALTH STATUS
19. Main disease diagnosed. (Can check medical records if available)
1= cardiovascular.
2= Neoplasms
3=Respiratory (including TB)
4= Endocrine (including Diabetes)
5= Bone fractures and related conditions (including osteoporosis)
6= Cancer (all kinds)
7= Other
8= None
20. When were you diagnosed with the disease? (When diagnosed in 19)
1= within past one month
2= past one year
3= one year and over
4= uncertain