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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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