Microsoft Word 4hr chi english App D. doc

Appendix D 
24-hour Dietary Intake Questionnaire 
6
 
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 
7
 
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 
8
 
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 
9
8. Was the amount of food that you ate yesterday about usual, less than usual, or more than usual? 
(1) Usual (Go to 9) (2) Less than usual (Go to 8a) (3) More than usual (Go to 8b) 
8a. What is the main reason the amount you ate yesterday was less than usual? 
(1) Sickness 
(2) Short of money 
(3) Traveling 
(4) At a social function, special meal or on a special day 
(5) On vacation 
(6) Too busy 
(7) Not hungry 
(8) Dieting 
(9) Fasting 
(10) Bored 
(11) Stressed 
(12) Other reason:______________________ 
8b. What is the main reason the amount you ate yesterday was more than usual? 
(1) Traveling 
(2) At a social function, special meal, or on a special day 
(3) On vacation or day off 
(4) Very hungry 
(5) Bored or stressed 
(6) Some other reason: ________________________ 
9. How could you describe your current dietary habit? [Show card] 
(1) 
No special diet, I eat almost everything 
(2) 
Vegetarian 
(3) 
Special diet:__________________________ 

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