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NICOLA NUTRITION Self-Completion Questionnaire Participant Unique Reference (to be completed by nurse) Date of completion D D M M Y Y Y Y (to be completed by nurse) Food Frequency Questionnaire The next set of questions asks about your diet over the last year. For each food there is an amount shown, either a “medium serving” or a common household unit such as a slice or teaspoon. Please put a tick in the box to indicate how often, on average, you have eaten the specified amount of each food during the past year. Example: For white bread the amount is one slice, so if you ate 4 or 5 slices a day, you should put a tick in the column headed “4-5 per day”. Non FOODS AND AVERAGE USE LAST YEAR AMOUNTS BREAD AND Never 1-3 Once 2-4 5-6 Once 2-3 4-5 6+ SAVOURY or less per a times times a day times times times BISCUITS than month week a a per per per day (one slice or once a week week day day biscuit) month White bread and rolls ✓ 2 Example: For chips, the amount is a “medium serving”, so if you had a helping of chips twice a week you should put a tick in the column headed “2-4 per week”. Non FOODS AND AVERAGE USE LAST YEAR AMOUNTS POTATOES, Never 1-3 Once 2-4 5-6 Once 2-3 4-5 6+ RICE AND or less per a times times a day times times times PASTA than month week a a per per per day once a week week day day (medium month serving) Chips Example: For seasonal fruits such as strawberries and raspberries you should estimate your average use when the fruits are in season, so if you ate strawberries or raspberries about once a week when they were in season you should put a tick in the column headed “once a week”. Non FOODS AND AVERAGE USE LAST YEAR AMOUNTS Fruit Never 1-3 Once 2-4 5-6 Once 2-3 4-5 6+ (1 fruit or or less per a times times a day times times times medium than month week a a per per per day serving) once a week week day day month Strawberries, raspberries, Kiwi fruit ✓ 3 FOODS & AVERAGE USE LAST YEAR AMOUNT Never 1-3 Once 2-4 5-6 Once 2-3 4-5 6+ MEAT & FISH or less per a per per a day per per per (medium serving) than month week week week day day day once a month Beef; roast, steak, mince, stew or 1 casserole 0 1 2 3 4 5 6 7 8 1 Beef burgers 1 0 1 2 3 4 5 6 7 8 Pork; roast, chops, 1 stew or slices 1 0 1 2 3 4 5 6 7 8 Lamb; roast chops 1 or stew 1 0 1 2 3 4 5 6 7 8 Chicken or other 1 poultry e.g. turkey 1 0 1 2 3 4 5 6 7 8 1 Bacon 1 0 1 2 3 4 5 6 7 8 1 Ham 1 0 1 2 3 4 5 6 7 8 Corned beef, Spam, 1 luncheon meats 1 0 1 2 3 4 5 6 7 8 1 Sausages 1 0 1 2 3 4 5 6 7 8 Savoury pies e.g. 1 meat pie, pork pie, 1 pasties, steak & 0 1 2 3 4 5 6 7 8 kidney pie, sausage 1 rolls Liver, liver pate, liver sausage 1 0 1 2 3 4 5 6 7 8 Fried fish in batter 1 (fish & chips) 1 0 1 2 3 4 5 6 7 8 Fish fingers, fish 1 cakes 1 0 1 2 3 4 5 6 7 8 N 1 4
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