EATING HABITS AND FOOD & DRINKS PREFERENCES QUESTIONNAIRE

This survey asks questions regarding your eating habits and drinks commonly taken with your food
preferences that are relevant to your health. As your body is 80% water, the amount and quality of
water you take is hereby included. The information you provide will help the school understand more
about ways to help students prevent diseases. Your completed questionnaire will be held with utmost
confidentiality. Your responses are important as they will pave the way to determine potential
programs or menus to offer in the school canteen. There is a space reserved on the last page for any
comments you would like to share after completing the form. Thank you for your support!

FOOD AND DRINKS PREFERENCES

For each of the food listed, put a check on the box (✓) to indicate at what meal or snack time you
take these food and drinks in a day, how often, on average, you consume the food items specified,
and at what time or meal of the day you consume them.

Preparation Time of the Day Taken

Snacks

Raw or Fresh

Breakfast
Cooked

Canned
FOOD ITEMS

Frozen

Afternoon
Dinner
Lunch
Dried

Morning

Evening
DAIRY FOODS
Butter (added to food or bread)
Cottage or ricotta cheese
Ice cream
Margarine (added to food or bread)
Other cheese (plain or as part of a dish)
Skim or low fat milk
Whole milk
Yogurt
Other dairy foods (specify: ____________________)
FRUITS
Apples
Apricots
Avocado
Bananas
Berries
Grapefruit
Grapes
Guava
Guyabano
Kiwi
Lansones
Lemon
Mangoes
Mangosteen
Melon
Oranges
Papaya
 Preparation Time of the Day Taken
Snacks

Raw or Fresh

Breakfast
Cooked

Canned

Afternoon
Frozen

Dinner
Lunch

Morning
Dried

Evening
FOOD ITEMS

Peaches
Pears
Pineapple
Plums
Pomelo
Rambutan
Star apple
Watermelon
Other fruits (specify: __________________________)
VEGETABLES
Arugula
Bitter gourd (Ampalaya)
Broccoli
Brussels sprouts
Cabbage
Camote tops
Carrots
Cauliflower
Celery
Collard greens
Corn
Cucumber
Eggplant
Horseradish (Malunggay)
Lady’s fingers (Okra)
Lettuce
Lima beans
Malabar nightshade (Alugbati)
Mung bean sprouts (Togue)
Mung beans (Monggos)
Other peas, beans or lentils
Pechay
Spinach
String beans
Sweet potatoes
Tomatoes
Turnip
Water spinach (Kangkong)
White radish
Yams
Yellow squash
Other vegies (specify: ________________________)
POULTRY PRODUCTS AND MEATS
Bacon
 Preparation Time of the Day Taken
Snacks

Raw or Fresh

Breakfast
Cooked

Canned

Afternoon
Frozen

Dinner
Lunch

Morning
Dried

Evening
FOOD ITEMS

Beef
Beef loaf
Chicken (with skin)
Chicken (without skin)
Chicken liver
Chorizo
Corned beef
Eggs
Ham
Hamburger
Hotdogs
Lamb
Longaniza
Meat loaf
Pork
Pork liver
Salami
Sausage
Siomai
Spam
Tocino
Turkey (with skin)
Turkey (without skin)
Other products (specify: ______________________)
SEAFOODS
Bass fish
Catfish
Flounder
Mackerel
Milkfish
Mullet
Salmon
Sardines
Snapper fish
Swordfish
Tilapia
Tuna
Other fishes (specify: _________________________)
Clams
Crab
Eucheuma seaweed (Guso)
Mussels
Scallops
Sea grapes or green caviar (Lato)
 Preparation Time of Day Taken
Snacks

Raw or Fresh

Breakfast
Cooked

Canned

Afternoon
Frozen

Dinner
Lunch

Morning
Dried

Evening
FOOD ITEMS

Sea hare excretions (Lukot)

Shrimp
Squid
Other seafood (specify: ______________________)
SALADS
Fresh green salad
Fresh fruit salad
Fruit salad (processed ingredients)
Gelatin or gulaman
Other salads (specify: _________________________)
SWEETS, BAKED GOODS, CEREALS, MISC.
Biscuits
Breakfast cereal
Cake
Candies
Champorado
Chocolate
Cookies
Corn chips
Cornbread
Dark bread (including wheat pita bread)
Doughnut
French fried potatoes
Maja blanca
Mayonnaise dressing
Muffins
Munchkins
Nuts (hazelnut, cashew, almond, peanut, etc.)
Oil dressing
Pasta (spaghetti, lasagna, etc.)
Peanut butter
Pie (homemade)
Pie (ready-made)
Pizza
Potato chips
Potatoes (baked or boiled)
Rice
Rice muffin (Puto)
Rice porridge (Lugaw)
Silken tofu (Taho)
Sweet rice cake (Biko)
Thousand Island dressing
Vinegar dressing
Wafer
 Preparation Time of Day Taken
Snacks

Raw or Fresh

Breakfast
Cooked

Canned

Afternoon
Frozen

Dinner
Lunch

Morning
Dried

Evening
FOOD ITEMS

White bread (including pita bread)

Other items (specify: __________________________)
BEVERAGES
Beer
Cola
Decaffeinated coffee
Herbal tea
Lemon juice
Liquor (whiskey, gin, etc.)
Mango juice
Non-decaffeinated coffee
Non-herbal tea
Orange juice
Pineapple juice
Pomelo juice
Soda
Strawberry juice
Watermelon juice
Wine
Other beverages (specify: ____________________)

WATER INTAKE AND KIND OF WATER TAKEN PER DAY

Your body is 80% water. For each of the following items, please indicate the number of regular
glasses of water you take during different times of the day.

Number of Glasses of Water Taken

Waking Up

Afternoon
Breakfast

Bedtime
Morning
Snacks

Snacks
Lunch

Dinner

Dinner
Before

Before

Before
Lunch

KIND OF WATER / NAME / SOURCE

Upon

After

After

After

Tap Water
Bottled Water (Nature’s Spring)
Bottled Water (Absolute)
Bottled Water (Wilkins)
Bottled Water (Others, specify: __________)
Water from Refilling Stations
Kangen Water
BEVERAGES TAKEN PER DAY

For each of the following items, please indicate the number of regular glasses of the beverages you
take during different times of the day.

Number of Glasses of Beverages Taken

Waking Up

Afternoon
Breakfast

Bedtime
Morning
Snacks

Snacks
Lunch

Dinner

Dinner
Before

Before

Before
Lunch
BEVERAGE

Upon

After

After

After
Coffee
Juice
Wine
Beer
Liquors
Tea
Soft drinks
Other beverages (specify: ______________)

PERSONAL EATING HABITS

About
None

Most
Little

half
How much freedom or choice do you have for:

All
Food shopping?
Planning meals?
Preparing meals?
Choosing beverages?
Choosing water to drink at home?
Choosing water to drink outside your home? Convenience
Carinderia
Restaurant

Neighbors
Relatives/
Fast Food
School
Home

Chain
Store

In a typical week, where do you usually take the

following meals and drinks:

Breakfasts?
Lunches?
Dinners?
Morning Snacks?
Afternoon Snacks?
Evening Snacks
Water?
Drinks?
 Disagree

disagree
Strongly

Strongly
Neutral
Agree
agree
How much do you agree or disagree with the following statements?

I can’t get vegetables in restaurants.

Members of my household won’t eat vegetables.
Fruits are available where I live.
I like most vegetables.
I don’t like fruits.
I think vegetables are inexpensive.
I don’t have time to prepare meals made of vegetables.
I usually keep fruits at home.
I usually buy and eat lots of vegetables.
I can’t afford to buy fruits.
I can’t buy vegetables where I live.

Who usually prepares food at home?

o Grandparent/s o Siblings o House cook
o Parents/s o Me o Others (specify: _____)

PERSONAL PROFILE

Name: ___________________________________________________________________________________________
Gender: ______________________________ Birthdate: ________________________ Age: ___________________
Weight: ______________________________ Height: ________________________ BMI: _______________________
Complete Address: ______________________________________________________________________________
Father’s Name: __________________________________________________________________________________
Father’s Occupation: _____________________________________________________________________________
Mother’s Name: __________________________________________________________________________________
Mother’s Occupation: ____________________________________________________________________________

COMMENTS / SUGGESTIONS:
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