Questionnaire - Page 2 of 9 (1014 maximum possible questions)

Last updated: May 12, 2008

SYMPTOMS: FOOD: INTAKE
119.	How often do you consume tofu, soybean curd, soy milk or cooked soybean products?	Never / don't know Once per month or less Once per week or less A few times per week At least daily
120.	Do you consume fermented soy products such as tempeh, natto, miso or soy sauce?	Never / don't know Once per month or less Once per week or less A few times per week At least daily
121.	Do you consume dairy (milk/cheese/cream) products?	Don't know Never / rarely 1-6 times per week Some every day A lot / more than once daily
122.	How often do you consume ice cream? Please answer this question whether the product is milk, soy or rice based.	Don't know Never / rarely Once a week or so Several times a week Daily
123.	Do you consume fast food?	Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
124.	Aside from fast food, how often do you consume deep-fried foods?	Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
125.	On average, how many daily servings of fruits and vegetables do you eat?	None / under one / don't know 1 or 2 About 3 About 4 to 5 More than 5
126.	How often do you have salads? A large salad could count as two smaller salads.	Never / Rarely At least once per week 2-3 times per week / Don't know 4-7 times per week Large salads / more than once daily
127.	Refined sugar. Estimate how often you consume sugar-containing snacks (cookies, candy bars...), desserts (cakes, puddings...) or other servings of at least one tablespoon of sugar (for example in cereal, coffee...)? Do not include soft drinks here.	Don't know Rarely / Less than once per week About 2-3 times per week Roughly daily or almost daily A lot / more than once per day
128.	How much chocolate do you consume? A 'little' is defined as up to one standard chocolate bar (100gm / 3.5oz)."	Not applicable / don't know None / Rarely A little / more than once per week A lot / more than once per week Daily have more than one standard chocolate bar
129.	Hydrogenated oils / fats. How often, on average, do you consume them, not distinguishing good oil from bad? They are often found in margarines, cakes, biscuits, french fries, chips, and sweets for example.	Never On rare occasions / I try very hard to avoid them A few times per week About once a day More than once daily (average diet) / don't know
130.	Approximately how many tablespoons of flax oil, hemp, chia or candlenut oil do you consume on average per week? (3 tablespoons of flax seeds equals one tablespoon of flax oil.)	None / rarely / don't know One per week 2-3 per week 4-10 per week More than 10 per week
131.	Approximately how much fish oil or how many capsules of fish oil do you consume on average per day?	Don't know None / rarely Oil 1-2 teaspoons, capsules 1-3 Oil 1 Tablespoon, capsules 4-6 More than 1Tablespoon, more than 6 capsules
132.	How many tablespoons of safflower, sunflower, corn, soy, sesame, pumpkin or almond oil do you consume per week?	None / rarely 1-3 per week 4-7 per week / don't know 8-14 per week Definitely more than 14 per week
133.	How many tablespoons of olive oil do you use weekly?	Don't know None / negligable 1-3 4-9 Over 10 tablespoons
134.	How many servings of cold-water fish such as salmon, herring, sardines or mackerel do you consume on average per month?	None / rarely / don't know One Two Three to four Five or more
135.	How many servings of fish per month do you eat from the following list? Shark, swordfish, king mackerel, tilefish, Ahi, tuna, sea bass, halibut, marlin, pike, mahi-mahi, cod and pollack.	Don't know None / rarely Less than 2 per month 3 to 6 per month More than 6 per month
136.	How many servings of red meat do you have per week?	Don't know None Several times a week or less Around once per day Definitely more than once a day
137.	Do you consume processed meats? These would include hot dogs, bacon, salami, sausage, etc..	Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
138.	How many servings of chicken, turkey or other fowl do you have per week?	Don't know None Several times a week or less Around one per day Definitely more than one per day
139.	Do you eat refined white flour products, for example French, Italian or other white bread, bagels, pasta etc.?	Don't know Never / rarely No more than 3 times per week 4-7 times per week A lot / more than once daily
140.	Whether whole wheat or not, how often do you eat products made from wheat?	Never / rarely Once a day or less Couple times a day / uncertain Many times each day
141.	Do you consume many starchy foods? These are known as high glycemic index foods and include refined breads, pastas, potatoes, pancakes, cereals, bananas and other processed or sugary foods such as cakes, cookies, and other snacks.	Don't know Never / rarely Once a day or less 2 to 4 times a day 5 or more times each day
142.	Salt. How much added salt (salt that is not already in the food) do you consume on average?	None A little Average / don't know Above average A lot - I usually add salt and enjoy salted foods
143.	Being honest with yourself, do you feel that the amount of calories you are consuming is...?	Definitely not enough Probably not enough About right / don't know Probably too many Definitely too many
144.	How would you rate your overall fat / oil intake from food and supplements?	Extremely low Moderately low Average / don't know Moderately high Very high
145.	On average, how many raw egg whites do you consume in a week?	Don't know None at all Up to 2 per week / occasionally About 3 to 7 per week / moderate amounts 8 or more per week / high amounts
146.	On average, how many cooked egg whites do you consume in a week? This includes any egg whites hidden in prepared dishes, baked goods and products like mayonnaise.	Don't know None, in any form Up to 2 per week / occasionally About 3 to 7 per week / moderate amounts 8 or more per week / high amounts
147.	On average, approximately how many raw or cooked egg yolks do you consume in an average week? This includes any egg yolks hidden in prepared dishes, baked goods and products like mayonnaise.	Don't know None, in any form Up to 2 per week / occasionally About 3 to 7 per week / moderate amounts 8 or more per week / high amounts
148.	How often do you consume garlic?	Never / don't know Once per month or less Once per week or less A few times per week At least daily
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SYMPTOMS: FOOD: PREFERENCES
149.	Are there any foods that you eat often and would have difficulty giving up? Examples include bread, milk or cheese. If so, please make notes below.	Don't know No Probably Yes, definitely
150.	Are you a picky eater?	Don't know No Somewhat Definitely
151.	Are you vegetarian?	No Part-time Lacto-ovo vegetarian (eggs/dairy but no fish/fowl) Vegan (no animal products at all) Raw food only
152.	Apart from moral objections, do you have a distaste for meat?	Don't know No Yes, moderate Yes, definite
153.	Do you generally feel like eating breakfast?	Always / don't know Usually About half the time Usually not Never
154.	Do you crave (have a strong desire for) prepared wheat products such as bread or pasta?	Don't know No Yes, but I never eat wheat products Yes, and I eat wheat products occasionally Yes, and I eat wheat products often
155.	Do you crave coffee or sugar in the afternoon?	Don't know No Yes, moderately Yes, very much
156.	Do you crave greasy or fatty foods?	Don't know No Yes, moderately Yes, very much - I need some every day
157.	Whether or not you believe that salt is good for you, how much do you like salty foods?	I dislike salty food / food often tastes too salty I avoid salt when I can It makes no difference / don't know I often like some extra salt I really love/crave salt
158.	Do you crave sugar or sweets, other than chocolate?	Don't know No Yes, moderately Yes, very much - I need some every day
159.	Do you crave chocolate?	Don't know No Yes, moderately Yes, very much
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SYMPTOMS: FOOD: BEVERAGES
160.	What is your alcohol tolerance?	Very easily intoxicated (a couple of sips does it) I am easily intoxicated Average / don't know I am quite tolerant Very tolerant (I can drink all night)
161.	Have you ever consumed alcohol regularly?	No, none at all Never more than one drink per month Yes    More questions later...
162.	How many cups of caffeinated coffee do you drink per day?	None / don't know One Two Three Four or more
163.	How does coffee affect you? Adverse reactions include feeling 'wired', 'hyper' or jittery, nauseated or hungry.	I do very well on it It seems to benefit me slightly There is no particular effect / don't know Occasional adverse reaction Significant adverse reaction(s)
164.	This question is for coffee / tea drinkers only. Do the effects of caffeine seem to last a short time (fast metabolizer) with you or last for a long time slow metabolizer)?	Effects last a very long time Effects last somewhat longer Don't know / Doesn't apply / Average, I guess Effects don't seem to last that long Effects are very short lived.
165.	On average, how much fruit or vegetable juice do you consume per day? One cup is 8 fluid ounces, or about 250ml.	None / rarely / don't know 1 cup 2 cups (500ml - half a standard carton) 3 cups (750ml) 4 cups (1 liter - a standard carton) or more
166.	Do you consume non-herbal ('ordinary') black tea?	No / rarely / don't know About one cup per day About two cups per day About three cups per day Four cups or more per day
167.	Do you consume green tea?	No / rarely / don't know About one cup per day About two cups per day About three cups per day Four cups or more per day
168.	Do you consume soft drinks containing caffeine? (Soft drinks are non alcoholic. (Most soft drinks do contain caffeine. If unsure about those that you drink, answer this question assuming that they contain it.)	Never / rarely / don't know About once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
169.	Do you consume soft drinks that do not contain caffeine? (Most soft drinks do contain caffeine. If unsure about those that you drink, do not answer this question.)	Never / rarely / don't know About once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
170.	Do you consume soft drinks that contain sugar (not artificially-sweetened)?	Don't know Rarely, if ever / less than once per week 2-3 times per week 4-7 times per week A lot / more than once daily
171.	Do you consume low-calorie soft drinks (artificially-sweetened)?	Never / rarely / don't know About once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily
172.	Do you consume carbonated soft drinks?	Don't know Never / rarely Less than 3 times per week 4-7 times per week A lot / more than once daily
173.	How much plain water do you drink on average per day? One cup is 8 fluid ounces, or about 250ml.	Don't know / answer not present 1-2 cups (500-750ml) / don't know 3-5 cups (1 to 1.25 liters) 6-7 cups (1.5 to 1.75 liters) 8 cups (2 liters) or more
174.	Water consumption continued.	Don't know / answer not present 10 to 12 cups - about 3 quarts per day 12 to 16 cups - upwards of a gallon per day 6 quarts - about 1 1/2 gallons per day 2 gallons or more per day
175.	How is your level of thirst generally?	I am never thirsty Rarely thirsty Average / sometimes thirsty / don't know Frequently thirsty Always thirsty
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SYMPTOMS: ENVIRONMENTAL EXPOSURE
176.	Have you suffered exposure to diesel exhaust fumes (as opposed to exhaust fumes in general)? For example, diesel mechanics, truck drivers, working at a truck stop, etc.	No exposure / don't know Light exposure for a short time Light exposure for a long time Heavy exposure for a short time Heavy exposure for a long time / current exposure
177.	What has your exposure to air pollution (usually exhaust fumes) been?	Little or no exposure e.g. grew up in countryside Less than average Average exposure / don't know More than average High exposure: lived or worked near dense traffic
178.	Have you been exposed to solvents through lungs or skin, for example working with paints, glues or fuels?	No / don't know Mild, in the past only Heavy, in the past only Moderate current exposure Heavy current exposure
179.	Have you had significant exposure to specific herbicides? Include short-term intense contact or long-term low-level exposure.	Don't know No Phenoxy agents (2,4-D, agent orange, 2,4,5-T) Glyphosates (roundup, touchdown…) Yes, other
180.	Have you been esposed to bisphenol-A (BPA)?	Don't know / uncertain No, I have always avoided contact Yes, but in the past only Average exposure Above average exposure
181.	Are you exposed to chlorinated water either by drinking or bathing?	Don't know No Yes, use it for drinking only Yes, use it for bathing only Yes, use it for drinking and bathing
182.	Have you done any dust-producing work in pre-1970 building(s)?	No / don't know Yes, but didn't live there during the work Yes, and lived there while the work was done Yes, more than one job but did not live there Yes, more than one job and lived there
183.	Have you been exposed to treated lumber sawdust, for example as a carpenter?	No / don't know Mild, in the past only Heavy, in the past only Moderate current exposure Heavy current exposure
184.	Have you ever been diagnosed with mercury poisoning or toxicity?	Don't know Tests have confirmed there is no problem Yes, mild Yes, moderate Yes, severe
185.	Have you ever been diagnosed with heavy metal toxicity other than mercury?	Don't know Tests have confirmed there is no problem Yes, Mild Yes, moderate Yes, severe
186.	Have you been exposed to the element manganese? This most commonly occurs as a result of drinking water contaminated with manganese and also occurs in battery manufacturing and manganese processing.	Don't know No Possibly Probably Definitely / chronically
187.	Are you sensitive to cigarette smoke?	No / don't know Mildly Moderately Seriously Severely
188.	Are you sensitive to chemicals (paint, perfume, insecticides, exhaust fumes)?	No / don't know Mildly Moderately Seriously Severely
189.	Are you unusually sensitive to typical adult doses of prescription or over-the-counter medications? Indicators include regularly experiencing side-effects or finding that smaller-than-recommended doses usually suffice.	I don't use pharmaceutical drugs / don't know No, I am not It has been suggested Sometimes definitely Extremely
190.	Do you have Environmental Illness / Multiple Chemical Sensitivity?	No / don't know Probably - I have minor reactions Quite likely - I have definite reactions Definitely / has been diagnosed / severe reactions
191.	How easily do you sunburn?	Very easily Easily Average / don't know Slowly Very slowly
192.	During your lifetime, how much have you been exposed to the sun?	Don't know Limited exposure, rarely enough to sunburn Moderate exposure / occasional light sunburn Significant exposure / frequent light burns Extreme exposure / frequent severe burns
193.	How much sun exposure have you had during the past 6 months?	Very little/rarely outdoors/always fully covered A little skin exposure for under 1 hour per week Arms/legs in full sun for at least 1 hour per week Much of body in full sun at least 2 hours per week Whole body in full sun at least 4 hours per week
194.	Do you experience a rash from sun exposure?	Don't know No Occasionally Regularly on facial cheeks Regularly anywhere besides the cheeks
195.	Temperature. How does being in the cold affect you?	I can't take it well It makes no difference / don't know I enjoy it, find it invigorating
196.	Temperature. How does being in the heat affect you?	I can't take it well It makes no difference / don't know I enjoy it
197.	How well do you seem to be able to regulate your body temperature?	Don't know Very poorly Minor problem Normally / average Very well
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