Appendix D
24-hour Dietary
Intake Questionnaire
4
Individual Intake Form
Quick List of
Food Items
Column 1
Column 2
Column 3
Column 4
Coder use only
A.
Time
B.
Occa-
sion
A.
Food/Drink and
Additions
B.
Description of Food/Drink and
ingredient
How much of this
(FOOD) did you
actually (eat/drink)?
Where did
you obtain
the (FOOD)?
Food code
Amount
Occasion:
1.
Breakfast
2. Brunch
3. Lunch
4.
Dinner
5. Late night meal
6. Fruit
7. Food and/or
beverage break, snack, alcohol beverage or other beverage
8. Other (specify):_________________________
Source of food:
1. Homemade
2. Restaurant/cafeteria/fast food shop/deli 3. Food stall/hawker 4. Supermarket/Food store
5. Workplace
tuck shop
6. Day care
7. Friend/relative’s home
8. Party/BBQ/banquet/special event
9. Other (specify):________
Appendix D
24-hour Dietary Intake Questionnaire
5
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