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Aqua Aerobics - PE 245abcd
Spring 2004

Nutrition Assessment
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The assessment of nutrition involves looking at four key dietary factors:

  1. Prudent Diet habits referring to general nutritional balance.
  2. Calorie Control habits pertaining to weight loss and gain.
  3. Dietary Fat/Cholesterol referring to habits that affect cholesterol in the diet.
  4. Sodium or Salt Control which affects blood pressure.
All four of these dietary factors have an influence as to whether or not your diet contributes to an unusual risk of heart disease. Fill out each of the four questionnaires below to get an idea of where you stand.

 Answer each question according to your usual eating habits. Place the number corresponding to your answer in the space provided to the left of each question. Total these numbers at the end of each category.
 

Prudent Diet Questionnaire

_____ How much low fat or skim milk, yogurt, and cheese do you consume in a week?
  1. Consume at least 16 ounces milk or yogurt, or 3 ounces cheese per week.
  2. 8 ounces milk/yogurt or 1 ounce cheese per week.
  3. Only use it in cereal or consume it occasionally.
  4. Do not consume milk/yogurt/cheese at all.
_____ How often do you choose to eat potato chips, corn chips, taco chips, olives, nuts, or similar foods as snacks or with a meal?
  1. none or rarely
  2. occasionally 1-2 times per week
  3. 3-4 times per week
  4. 5 or more times per week
_____ How many times do you eat fruit per day?
  1. 7 or more
  2. 4-6 times
  3. 1-3 times
  4. none
_____ How many whole grain breads and cereals, raw fruits and vegetables, and bran products do you eat each day?
  1. 4 or more
  2. 3-4 servings
  3. 1-2 servings
  4. none
_____ Which describes your consumption of vegetables?
  1. Snack on raw vegetables and eat vegetables/salads with most meals.
  2. Eat salads and vegetables at one meal a day.
  3. Eat vegetables 2-3 times per week.
  4. Rarely eat vegetables.
_____ How many glasses of water do you drink in a day?
  1. 8 or more glasses
  2. 5-8 glasses
  3. 2-4 glasses
  4. one glass or none
_______Total Prudent Diet Questionnaire

Calorie Control Questionnaire

_____ Which most closely describes the amount of food you eat at one time?
  1. Select a reasonable portion, stop eating when full.
  2. Eat what is served and clean the plate.
  3. Eat additionalhelpings to satisfy taste.
  4. Eat until full and then eat desserts.
_____ If you watned todecrease caloric intake, which would you do:
  1. Cut down on meat, sauces, gravy, desserts, salad dressings.
  2. Limit portion sizes.
  3. Leave off bread and potatoes.
  4. Follow a crash diet for a few days
_____ How many alcoholic beverages do you consume?
  1. Rarely or never drink.
  2. 1-3 drinks per week
  3. 1-2 drinks per day
  4. 3 or more drinks on weekend days
_____ Do you ever eat until you are so full that you are uncomfortable?
  1. Rarely or on special occasions
  2. 1-2 times a month
  3. once a week
  4. every couple of days, or more
_____ How many sweets (candy, pastry, cookies, desserts, ice cream, sugar-based beverages) do you eat?
  1. only on special occasions or don't eat sweets
  2. 1-2 servings per day
  3. 3-4 servings per day
  4. 5 or more servings per day
_____ Which pattern of eating typifies your style?
  1. Regular meals at frequent intervals.
  2. Occasionally skipping a meal
  3. Skipping breakfast or lunch
  4. Skipping meals during the day and eating only the evening meal.
_____ Total of Calorie Control Questionnaire

Fat/Cholesterol Control Questionnaire

_____How often do you eat eggs for breakfast or another meal?
  1. once per week or none
  2. 2-3 times per week
  3. 4-6 times per week
  4. 7 or more times per week
_____ How man ytimes per week do you consume red meat (beef, steak, pork, bacon, lamb, ribs)?
  1. 2 times
  2. 3-4 times
  3. 5-6 times
  4. more than 7 times
_____ when you prepare or eat poultry (chicken, turkey, cornish hen) which of the following plans do you most closely follow:
  1. Chose white meat, remove skin and prepare by baking or broiling.
  2. Chose dark meat, skin removed, and bake or broil
  3. Bake or broil, skin on and serve with gravy
  4. Leave the skin on and fry
_____ When selecting a salad or sandwhich, which of the following "fillings" would you chose most often?
  1. lentils, kidney beans, peas, pinto, or garbanzo beans
  2. turkey, chicken, tuna, lean cuts of meats
  3. same as above with cheese
  4. ham, pastrami, chamburger, salami, frankfurter, bacon, with cream or hard cheese
_____ When you eat dairy products (milk, yogurt, ice cream, cheese) do you select:
  1. Only skim or .5% products
  2. only look for low-fat products 1-2%fat
  3. Choose regular ice cream and yogurt, but use lowfat milk
  4. Only chose whole fat content dairy products.
_____If you were having potatoes would you choose:
  1. boiled or baked with no added fat (butter, margarine, sour cream)
  2. boiled or baked with polyunsaturated margarine/yogurt
  3. boiled or baked with margarie/butter and sour cream
  4. french fried, hash browns
_____ Total Fat/Cholesterol Control Questionnaire

Sodium/Salt Control Questionnaire

_____ How frequently do you add salt to your food after it is served at the table?
  1. Never
  2. 1-2 times per week
  3. about once a day
  4. with almost all meals
_____How many times do you eat at a "fast food" restaurant?
  1. rarely or always selecting a "salad bar" meal
  2. once a week
  3. 2-3 times per week
  4. 4 or more times per week
_____ How often do you eat any of the following foods: hot dogs, bologna, luncheon meat, bacon, ham, sausage?
  1. rarely or never
  2. 1-2 times per week
  3. 3-4 times per week
  4. daily
_____ In what form do you most frequently purchase food or meal preparations?
  1. fresh
  2. canned or frozen without salt
  3. canned without sauces
  4. canned, frozen, or dry with sauces and/or seasonings
_____ While preparing meals or when eating out, how frequently do you add any or all of the following items to your food? mustard, pickles, relish, soy sauce, ketchup, meat tenderizer, MSG?
  1. rarely or never
  2. 1-2 times per week
  3. 3-4 times per week
  4. daily
_____ Total Sodium/Salt Control Questionnaire

Questionnaire Evaluation and Submission

Scoring results for the questionnaires

 Excellent = 6-8 points
Good = 9-12 points
Fair = 13-16 points
Poor = 17-20 points
Very poor = 21-24 points

Copy, complete, and submit via email your questionnaire results using the following format: