QUESTIONNAIRE SHEET

Research title: Relationship Between Dietary Habit and Ucler Disease in Teenagers.
Research instructions
a. Read the questions carefully so you can understand
b. Choose one of your answers by putting a check mark in the space that are provided according to
the answer of your choices
c. Each number can only be filled with one answer
d. Each answer is requested to give an honest answer
e. Please fill all the answers in this questionnaire (and make sure that nothing is missed).

A. Demographic Data
Filling Date :
Name (Initials) :
Age :
Gender : [ ] Male [ ] Female
Education :
*) you can fill this table with checklist [√]

No Question Yes No
Do you eat 3 times a day?
1    
2 Do you eat less than 3 times a day?    
3 Do you eat at the same time every day?
   
4 Do you eat when you feel hungry?    
5 Do you eat small portions but often?    
6 Do you eat directly in large portions (4-5)?
   
Do you often eat spicy food?
7    
8 Do you often like sour food?    
9
Do you often consume instant food?    
10
Do you prefer snacking to eating rice?    
11 Do you have a history of stomach ulcers?    
12 Do you often feel burning in the stomach?    
13 Does your appetite often decrease?    
Do you often have heartburn?
14    
15 Do you often feel nauseous?    
Do you often vomit?
16    
17 Is your stomach often bloated?    
18 Do you often burp?    
Does your stomach relapse when you eat spicy
food?
19    
20 Does your stomach relapse when you eat too late?