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Table 7 English translation of an original survey questionnaire designed by the authors including 40 questions in terms of biometric data, anthropometric characteristics, family and environmental situation, nutritional and lifestyle behaviors

From: Association of physical fitness with quality of life in community-dwelling older adults aged 80 and over in Poland: a cross-sectional study

No. Item Answer
1 Name and surname  
2 Anthropometrics Body height [cm]: _ _ _ _ Weight [kg]: _ _ _ _
3 Birthday Age [years]: _ _ _ _ Date of birth: _ _ / _ _ / _ _ _ _
4 Sex [W/M]  
5 Marital status  
6 Lonely (since when?)  
7 Number of children  
8 Number of siblings  
9 At what age your siblings died?  
10 Siblings died of the causes Natural: Unnatural (accident, war):
11 At what age your parents died? Mother: Father:
12 Father died of the causes Natural: Unnatural (accident, war):
13 Learned profession  
1.1.1.14 Level of education a) Basic
b) Vocational
c) College
d) Higher
15 The character of professional work Mental Physical
16 Place of residence City Village
1.1.1.1.17 Cigarettes smoking a) I don’t smoke and I haven’t smoked
b) I’ve been smoking, I don’t currently smoke
c) I smoke 1–10 cigarettes a day
d) I smoke 10–20 cigarettes a day
e) I smoke more than 20 cigarettes a day
1.1.18 Alcohol consumption a) I do not drink alcohol (abstinence)
b) I consume alcohol on occasion
c) I consume alcohol frequently (once a week and more often)
19 Living conditions Good Average Bad
20 Material status Sufficient Insufficient
1.1.1.21 How many main meals do you eat during the day? a) Two or three
b) More than three
c) Only one
d) Very variously
1.1.22 How many times a day do you snack between meals (e.g., cookies, candy bars, bread, meat, etc.)? a) Not at all
b) One or two
c) Three or more
1.1.1.23 How often do you eat red meat, such as beef, lamb, pork and their preserves (sausages, cold cuts, and pâtés)? a) Twice a week or less frequently
b) Three or four times a week
c) Almost every day
d) Not at all
1.1.24 How often do you eat fresh fruit and vegetables (raw or cooked)? a) Twice a day and more often
b) Almost every day
c) Less than four times a week
1.1.1.25 How often do you eat products such as brown, unshelled rice, thick groats, whole meal bread, oatmeal? a) At least once a day
b) 3–6 times a week
c) Less than three times a week
d) Not at all
1.1.1.26 How many times a week do you eat fried food? a) Almost every day
b) About three times a week
c) Once a week or less frequently
d) Not at all
1.1.27 Do you eat fast-food (hot dogs, hamburgers, pizzas), salty and fatty snacks (chips, sausages, crackers)? a) Yes
b) Sometimes
c) Not at all
1.1.28 How often do you eat fish? a) Twice a week or more often
b) Less than once a week
c) Not at all
1.1.1.29 How often do you eat butter, drink whole fat milk or use cream? a) 3–4 times a day
b) Once a day
c) Several times a week or less frequently
d) I avoid fatty additives
1.1.1.30 How many cups (glasses, mugs) of coffee do you drink a day? a) Two or less
b) Three-four
c) More than five
d) Not at all
1.1.1.31 How many glasses (cups) of sweetened drinks do you drink a day? a) Two or less
b) Three-four
c) More than five
d) Not at all
1.1.1.32 Do you often eat sweets (e.g., chocolate, candies, cakes)? a) Every day or almost every day
b) About three times a week
c) Once a week or less frequently
d) Not at all
1.1.33 How many liquids do you drink a day (water, tea, soup)? a) About 3–6 glasses
b) About 6–10 glasses
c) More than 10 glasses
1.1.34 Do you sometimes eat late at night? a) Yes
b) Sometimes
c) No
1.1.35 Do you sometimes eat in a hurry (e.g., breakfast)? a) Yes
b) Sometimes
c) No
1.1.1.1.36 How often do you check your weight? a) Everyday
b) Once a week
c) Once a month
d) Once every six months
e) Not at all
1.1.1.1.1.1.37 What kind of products did you eat as a child? a) Meat
b) Milk, butter, cream
c) Breads
d) Sweets
e) Fruit
f) Vegetables
g) Fish
1.1.1.1.1.1.38 Assign the following products to the individual floors of the health pyramid for seniors: a) Meat, cold cuts, dairy products
b) Liquid, water, tea
c) Carbohydrates (bread, cereals, rice)
d) Fats, sweets, red meat
e) Vegetables and sweets
f) I don’t know what it is
39 What diseases do you suffer from?  
1.1.1.40 Fill the values of the following tests: a) Glucose level: _ _ _
b) Total cholesterol level: _ _ _
c) Blood pressure: _ _ _ / _ _
d) Hypertension (yes/no): _ _