1) Circle your gender: Male Female
2) Circle your age: 13 14 15 16 17 18 19
PART A: FISH
3) Do you eat fish for any of your meals? If No, skip to PART B
Yes No
4) On average, how many meals per week do you eat fish?
1 2 3 4 5 6 7 8 9 10+
5) Fill out the chart accordingly.
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Check this box if you eat the type of fish
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# of Times consumed per week
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Average Amount Each Time
Small- 1 palm full
Medium- 2 palms
Large- 3 palms
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Scallop
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Crab
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Halibut
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Salmon (Fresh)
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Mackerel
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Sea Bass
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Shark
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Swordfish
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Cod
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Trout
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Lobster
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Tuna (Fresh)
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Tuna (Canned)
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Shrimp
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PART B: BEVERAGES
6) What type water do you drink most?
Tap Bottled
7) Fill out the chart accordingly
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Check this box if you drink this
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# of Times consumed per week
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Average Amount Each time
(how many bottles or cups)
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Coca-Cola Classic
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Minute Maid Juice Box
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Chocolate Milk
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Energy Drinks
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A&W Root Beer
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Dr. Pepper
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Kool-Aid Jammers
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Sunny-D
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Powerade
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Pepsi
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7-Up
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Lipton Green Tea
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Snapple Iced Tea
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PART C: MISCELLANEOUS
8) Fill out the chart accordingly
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Check this box if you eat this
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# of Times consumed per week
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Average Amount each time
Example. 1, 2, 3..
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Quaker Oatmeal to Go
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Heinz BBQ Sauce
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Hershey’s Chocolate Syrup
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Kraft BBQ Sauce
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Nutri-grain Cereal Bars
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Smucker’s Strawberry Jelly
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Pop-Tarts
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Yogurt
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Jell-O
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Campbell’s Soup
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Heinz Ketchup
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Pancake syrup
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