Below are different food options for breakfast, lunch, dinner and a snack.  Please choose one item from each category that you would most likely consume by clicking the small dot to the right of the foods.

Please answer all the questions!

Age   

1.       Breakfast

oatmeal    

   Mushroom, Spinach and Feta Omelet    

                       

Cereal Diet      

 blueberry cream muffin whole                                   

2.       Lunch

http://www.carlosandgabbys.com/chicken%20burrito.jpg      

   Skinny Creamy Chicken Noodle Soup | gimmesomeoven.com    

http://fressers.files.wordpress.com/2009/12/dsc_40131.jpg?w=500&h=334               

       http://www.mccormick.com/-/media/Recipe%20Photos/McCormick/Main%20Dishes/787x426/Grilled%20Chicken%20Salad%20Supreme.ashx    

 

3.       Dinner

 

http://images.wisegeek.com/steak-and-fries.jpg                                  

  http://motherscircle.net/wp-content/uploads/2012/11/salmon-dinner.jpg                                    

http://1.bp.blogspot.com/-GaZh8F7NZDw/T-Kisv_5N3I/AAAAAAAACmk/2VfmdWYh4JU/s1600/cheeseburger_1.jpg                                              

  http://3.bp.blogspot.com/_6SjWNVl-vuo/TSo0B9MaEJI/AAAAAAAAAQQ/GIpnryU8gxM/s1600/Pasta+Puttanesca.jpg                   

 

 

4.       Snack

http://media.tumblr.com/tumblr_lmg2uyjncn1qj3maz.jpg                                       

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSKp4DVHQHuQXOk0MBk5xmbFx0H7c_lh-UN3P48RYHux2UIE7m17A                      

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcQG93y66mkglKHe5L3y-r2Sca_SiQSuc4f3GsgyoICEzcCW7fd7

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcQG93y66mkglKHe5L3y-r2Sca_SiQSuc4f3GsgyoICEzcCW7fd7

http://www.grubgrade.com/wp-content/uploads/2009/05/lays_classic.gif                                                         

     http://blogs.houstonpress.com/hairballs/snickers_bar010511.jpg                                     

 

 

 

5.    What is your gender?

 

             Male

            Female

             Decline to respond

 

6.    How many hours of sleep did you get last night?

(Please include whole hours as well as partial.  For example: 6 hours and 15 minutes)

            hours   minutes

 

7.    How many hours of sleep do you normally average on a weeknight?

Please include whole hours as well as partial.  For example: 6 hours and 15 minutes)

            hours   minutes

 

For the following chart - please indicate the likelihood of falling asleep during the event listed (0 = no chance to  3 = happens most often)
SITUATION CHANCE OF DOZING
Sitting and reading 0      1          2          3
Watching TV 0      1          2          3
Sitting inactive in a public place (e.g a theater or a meeting) 0      1          2          3
As a passenger in a car for an hour without a break 0      1          2          3
Lying down to rest in the afternoon when circumstances permit 0      1          2         
Sitting and talking to someone 0      1          2          3
Sitting quietly after a lunch without alcohol 0      1          2          3
In a car, while stopped for a few minutes in traffic 0      1          2          3

8.    In a given week, how many days do you engage in a physical activity? (sports, running, gym, etc.)

0       1          2          3          4          5 or more

 

9.    Why do you engage in these activities?

 

To lose weight

To improve or maintain physical appearance

To have fun

To be able to eat whatever you want

No reason

              

10.    How would you describe your mood on an daily basis?

 

Angry

Sad

Fair

Happy

Other

             

11.    Do you have a Job?

 

Yes

No

From time to time but not regular

       

12.    Do you use tobacco (nicotine) products?

             No Nicotine      Once a week      2-3 times a week       4-5 times a week     every day

        

13.  Do you use Alcohol products?

             No alcohol      Once a week      2-3 times a week       4-5 times a week     every day

 

14.  What time do you go to bed?

             8-10 pm     10:30pm - 12am      12:30am -2am       Depends on the night  

 

15. Do you take naps?

Yes           No           From time to time but not regular

 

16.  How do you rate you quality of your sleep 1(poor) -------------------5(excelent)  

 

17.  When you are lying down to sleep what do you think about?