Check the answer which best describes the way you have been eating over the past
month.
1. How many ounces of ground beef or burgers (beef or pork) do you eat? *
___ 1. I do not eat meat.
___ 2. I eat 3 ounces or less per day.
___ 3. I eat 4-6 ounces per day.
___ 4. I eat 7 or more ounces per day.
2. How often do you eat these meats: regular bologna, salami, hot
dogs, corned beef, spareribs, sausage, bacon, braunsweiger, or liver? Do not
count others.
___ 1. I do not eat any of these meats.
___ 2. I eat them about once per week or less.
___ 3. I eat them about 2 to 4 times per week.
___ 4. I eat more than 4 servings per week.
3. How often do you eat poultry, chicken, turkey, etc. without skin?
___ 1. I do not eat poultry.
___ 2. I eat poultry 3 ounces or less per day.
___ 3. I eat 4-6 ounces per day.
___ 4. I eat 7 or more ounces per day.
4. How many ounces of fish do you usually eat? *
___ 1. I do not eat fish.
___ 2. I eat fish 3 ounces or less per day.
___ 3. I eat 4-6 ounces per day.
___ 4. I eat 7 or more ounces per day.
5. How much cheese do you eat per week?
___ 1. I do not eat cheese.
___ 2. I eat whole milk cheese less than once a week and/or use only low fat
cheese such as diet cheese, low fat cottage cheese, or ricotta.
___ 3. I eat whole milk cheese once or twice per week (such as cheddar,
swiss, Monterey jack).
___ I eat whole milk cheese three or more times per week.
6. What type of milk do you use?
___ 1. I use only skim or 1% milk, or don't use milk.
___ 2. I usually use skim milk or 1% milk, but use others occasionally.
___ 3. I usually use 2% or whole milk.
7. How many visible egg yolks do you use per week?
___ 1. I avoid all egg yolks or use less than one per week and/or use only
egg substitute.
___ 2. I eat 1-2 egg yolks per week.
___ 3. I eat 3 or more egg yolks per week.
8. How many ounces of do you usually eat meatless main dishes? *
___ 1. I do not eat meatless main dishes.
___ 2. I eat less than 3 ounces each day.
___ 3. I eat 4-6 ounces per day.
___ 4. I eat 7 or more ounces per day.
9. How many commercial baked goods and how much regular ice cream do you usually
eat? (Examples: cake, cookies, coffee cake, sweet rolls, donuts, etc. Do not
count low fat versions.)
___ 1. I do not eat commercial baked goods and ice cream.
___ 2. I eat commercial baked goods or ice cream once per week or less.
___ 3. I eat commercial baked goods or ice cream 2 to 4 times per week.
___ 4. I eat commercial baked goods or ice cream more than 4 times per week.
10. What is the main type of fat you cook with?
___ 1. I use nonstick spray or I do not use fat in cooking.
___ 2. I use liquid oil (Examples: safflower, sunflower, corn, soybean,
and olive oil.)
___ 3. I use margarine.
___ 4. I use butter, shortening, bacon drippings, or lard.
11. How often do you eat snack foods such as chips, fries or party crackers?
___ 1. I do not eat these snack foods.
___ 2. I eat one serving of these snacks per week.
___ 3. I eat these snacks 2 to 4 times per week.
___ 4. I eat these snack foods more than four times per week.
12. How often do you eat fried foods like French fries, egg yolk, etc.?
___ 1. I do not eat any of these foods.
___ 2. I eat them about once per week or less.
___ 3. I eat them about 2 to 4 times per week.
___ 4. I eat more than 4 servings per week.
13. How often do you prepare foods by adding butter or margarine to the pan?
___ 1. I do not add any butter or margarine to the pan.
___ 2. I add this fat about once per week or less.
___ 3. I add this fat about 2 to 4 times per week.
___ 4. I add this fat more than 4 per week.
14. How often do you add butter or margarine at the table?
___ 1. I do not add any butter or margarine to my food.
___ 2. I add this fat about once per week or less.
___ 3. I add this fat about 2 to 4 times per week.
___ 4. I add this fat more than 4 per week.
15. How often do you use salad dressing or mayonnaise at the table?
___ 1. I do not add any butter or margarine to my food.
___ 2. I add this fat about once per week or less.
___ 3. I add this fat about 2 to 4 times per week.
___ 4. I add this fat more than 4 per week.
16. How often do you eat desserts and sweets?
___ 1. I do not add any this food.
___ 2. I add this food about once per week or less.
___ 3. I add this food about 2 to 4 times per week.
___ 4. I add this food more than 4 per week.
17. What spread do you usually use on bread, vegetables, etc?
___ 1. I do not use any spread.
___ 2. I use diet or light margarine.
___ 3. I use margarine.
___ 4. I use butter.
18. How often do you eat as a snack candy bars, chocolate, or nuts?
___ 1. Less than once per week.
___ 2. One to 3 times per week.
___ 3. More than 3 times per week.
19. When you use recipes or convenience foods, how often are they low fat?
___ 1. Almost always.
___ 2. Usually.
___ 3. Sometimes.
___ 4. Seldom or never.
20. When you eat away from home, how often do you choose low fat foods?
___ 1. Almost always.
___ 2. Usually.
___ 3. Sometimes.
___ 4. Seldom or never.
21. What serving size do you usually eat?
___ 1. Usually eat always eat small portions.
___ 2. Usually eat less than 3 oz or less.
___ 3. Usually eat between 4-6.9 oz.
___ 4. Usually eat 7 or more oz.
To Score: Add the points for each answer. If you have 24 or less, your diet is
moderate to low in fat and cholesterol. If your score is greater than 24, look
for high fat choices you could change.
Information provided by Northwest Lipid Research Clinic, University of Washington, Seattle. For
information about validity and scoring see Retzlaff, et al, and American Journal of Public Health,
February 1997. Northwest Lipid Research Clinic
University of Washington
325 Ninth Avenue, Box 359720
Seattle, WA 98104
Tele 206/341-4404; e-mail retz@u.washington.edu