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
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): _ _ | ||||
