GCRC Nutrition | Educational Material

AMN Trial-Monthly Dietary Questionaires
Take a moment to think about what you have eaten over the past month, recalling
all the meals and snacks and when you ate out. Please try to answer all of the
following questions.
Study ID: Date: (mmddyyyy)
Foods Never 1-3 times/month 1-2 times/wk 3-4 times/wk 5 and more/wk Daily
Skim Milk, fat free yogurt
Low Fat Milk, low fat yogurt 1% fat, 2% fat
Whole Milk, whole milk yogurt
Fat free margarine
Low fat margarine
Regular margarine
Butter
Fat Free Salad Dressing/Mayonnaise
Low fat Salad Dressing/Mayonnaise
Regular Salad Dressing/Mayonnaise
Cooking oil
Skinless Turkey, Chicken Breast (whole or ground)
Fried Chicken
Beef or Lamb (whole or ground)
Fat Free Hot Dog
Regular Hot Dog
Bacon or Breakfast Sausages
Egg Beaters or Egg Whites
Whole Egg
Fat Free Cheese by itself or in Pizza and other cooked dishes
Regular Fat Cheese
Baked Potato chips, Fat Free Pretzels
Fat Free Cake or Cookies
Regular Cake or Cookies
Fat Free Ice Cream
Regular Ice Cream
Fruit or Juice
Vegetables and Salad
Others: Please write in      
Please indicate how often you take supplements:
Type of Supplements Never 1-3 times/month 1-2 times/wk 3-4 times/wk 5 and more/wk Daily
Study Oil
Walnut Oil
Multivitamins with or without minerals
Ensure/Slim Fast/Carnation Instant Breakfast/Boost
Calcium with or without D
Vitamins Biotin/E/D/C/B12
Minerals: Iron/Potassium/Selenium/Magnesium
Flaxseed/Flaxseed Oil
Fish Oil/Omega-3
Evening Primrose
Fiber
Carnitine
Aspirin
Chromium Picolinate
Thank you for your time.