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Cctsi.ucdenver.edu

Food Preferences, Caffeine-free
You are part of a research study in which we will be providing meals for you. It is vital to the study that you eateverything that we give you, so we need to know what you like and what you don't like to eat. Please use this form tochoose which foods you will and won't eat during the study.This survey generally takes 7-15 minutes to complete. Primary Phone: Enter with no commas, dashes, or spaces (eg. 7207771234)Please indicate the best number to call you, where we will be able to talk to you directly within a few hours (used only ifwe have questions or something is wrong at the time of diet pick-up) EATING HABITS
This page asks about your food and beverage consumption on a NORMAL WEEKDAY.
This study requires that you eat ALL of the food that we give you. For each day, this will typically be breakfast, lunch, dinner, and one snack. You can "mix and match" the different food items that you are given (eg. add a cookie from your snack to your lunch) AS LONG AS ALL FOOD IS CONSUMED ON THAT DAY. Are you willing to consume such a diet? Sorry we cannot design a special diet for you if you are unwilling to eat all of the food that we provide.
Thanks for your interest in the study. Please contact the study co-ordinator for further information.
Do you normally drink coffee or tea on a weekday? THIS IS A STRICTLY CAFFEINE-FREE DIET. No coffee or tea are allowed. Are you willing to go without coffee/tea or drink decaffeinated coffee/tea for several days? Sorry, we cannot design a caffeine-free diet for you if you cannot go for a few days without coffee or tea.
Thanks for your interest in the study. please contact the study co-ordination for further details.
How many times do drink coffee or tea per day? Please state type of coffee or tea that you normally drink (choose from: decaf coffee, regular coffee, black tea, EarlGrey tea, chamomile tea, green tea) Which of the following do add to your coffee or tea? (Check O CreamerO Milk, wholeO Milk, reduced fat (1 or 2%)O Milk, non fatO Soy or rice milkO None of these Which of the following do add to your coffee or tea? (Check O Sugar, 2 teaspoonsO Sugar, 3 or more tspO Sugar substituteO SplendaO EqualO None of these What do you eat for breakfast on a typical weekday? If you don't normally eat breakfast, what would you be willing to eat for breakfast?It's OK to describe more than one meal that you would normally eat. Please be specific (eg. Special K cereal plus 2%milk; 2 slices white toast, one with jam, one with peanut butter; one boiled egg plus heat toast with butter) Do you normally have a drink with your breakfast? What do you normally drink with your breakfast on a weekday? What do you normally eat for lunch on a weekday?It's OK to describe more than one meal that you would normally eat. Please be specific (eg. Lean Cuisine chicken meal;sandwich with turkey, lettuce, tomato, and mustard; pepperoni pizza, soda, and chips).
What do you normally eat for dinner on a weekday? It's OK to describe more than one meal that you would normally eat. Please be specific (eg.stir-fry with beef, snap peas,mushrooms, broccoli, pea shots and peanut sauce; Domino's vegetable pizza and garlic bread; spaghetti with meatsauce, white bread, and green salad with Italian dressing).
How many snacks do you eat on a normal weekday? What are your favorite snacks? (eg. cookies, ice cream, chips, popcorn) How many times do you normally drink soda, energy drinks, THIS IS A STRICTLY CAFFEINE-FREE DIET. We do not stock any caffeine-free sodas. Are you willing to go without Sorry, we cannot design a caffeine-free diet for you if you cannot go without certain beverages (eg. Coke, Pepsi) for afew days.
Thanks for your interest in the study. Please contact the study co-ordinator for further details.
SPECIAL DIET RESTRICTIONS OR LIMITATIONS
We need to check that we can cater for all of your special dietary needs. We are very flexible and
tailor your diet specifically for you but we cannot accommodate ALL dietary needs. This section
notifies us of any special factors that we need to consider when designing and preparing your diet.
Do you have any of the following conditions? O Food AllergiesO Medical condition with dietary restrictionsO Vegetarian or veganO Beliefs or religious rules restricting diet or specifying food preparation techniquesO Difficulty chewing and/or swallowingO Restricted meat intakeO Restricted fat intakeO Gluten-free dietO None of these Please explain which food/s you are allergic to and your reaction when you eat that food/s.
Which foods do you omit from your diet (eg. some meat, all meat, fish, eggs, milk, cheese, different types of fat)? Please provide the name of your medical condition, how long you have had this condition, and what dietary restrictionsyou have been prescribed.
Please explain any dietary restrictions or food preparation requirements that you have.
Please describe your swallowing and/or chewing problems and list the foods that you find most easy to chew/swallowand which foods you CANNOT chew/swallow.
We cannot accommodate a gluten-free diet. All meals are prepared in a kitchen that regularly handles foods containinggluten and we do not have separate mixing bowls or cooking pans for gluten-free foods. Thanks for your interest - we regret that we cannot accommodate your diet at this time. FOOD PREFERENCES
On the next few pages, we will ask whether or not you will eat an extensive list of foods. Please
answer carefully as this study requires that you eat ALL of the food that we give you and NO
SUBSTITUTIONS CAN BE MADE AFTER THE DIET IS PREPARED!
This study has very specific dietary targets so it can be hard to design this diet if you are very fussy
or picky eater.
Be aware that if you answer "Yes" to eating a food, you may receive that item several times over a
few days. So, if you state that you eat baby carrots, you could receive them as a snack on day 1, as
part of a stir-fry on day 2, and as a sandwich item on day 3! So, if you only enjoy a food item
occasionally, mark "No". Mark "Yes" ONLY if you will eat that food multiple times and in different
Along the same lines, if you mark that you will eat mayonnaise, you could receive it on a sandwich or
as part of a dish such as tuna salad. If you will eat mayonnaise as part of tuna salad but won't eat it
on a sandwich, mark "No".
Are you willing to eat ALL of the food that we provide with no substitutions or changes (if we do not give you any foods that you mark "No" to in this questionnaire!) Are you willing to accept that the nature of the diet may be more limited and repetitive than your usual diet due to the strict dietary targets needed by the study? Sorry, but we cannot design a specialized diet for you that meets the study's strict dietary targets if you cannot eat thediet that we provide and accept that it may be more limited and repetitive than your usual diet.
Thanks for your interest in the study. Please contact the study co-ordinator for further details.
BREADS & CEREALS
Will you eat the following food items? (You MUST answer every question)
Granola Bar (choc chip OR peanut butter) Will you eat the following? (Remember that you could receive a food more that once!)
VEGETABLES
Will you eat the following:
DAIRY FOODS
Will you eat the following? (remember that you could yogurt as a snack every day for 3 days, as an
example):
Will you eat the following:
Turkey (breast, fresh, roasted in-house) PREPARED MEALS
Prepared meals include frozen entrees (designated in the list below) and foods that are weighed,
combined, and cooked in-house.
Will you eat the following:
Fettuccine Alfredo (frozen, Lean Cuisine) Pizza (assembled in-house and then frozen) SNACK FOODS
Will you eat the following?
CONDIMENTS
Will you eat the following?
SALAD DRESSING/SAUCES
Will you eat the following?
BEVERAGES
(THIS IS THE LAST SCREEN!!)
Will you drink the following?
COMMENTS/QUESTIONS/CONCERNS?
List them here.
THIS IS THE FINAL SCREEN!!!
Please list any brand preferences that you may have (eg. only eat Kellog's brand Raisin Bran or Tropicana orange juice;will not eat Stouffer's mac and cheese or Post cereals; etc).
List any food preparation stipulations that you have (eg. will only eat cereal with yogurt not milk; will only eat cereal dry;will only eat sandwiches with no condiments or butter; will only eat bread toasted; will not eat beef cooked abovemedium-rare; will only eat a hot meal for dinner; will not eat cold snacks, etc) Do you have any other questions, comments, or concerns?

Source: http://cctsi.ucdenver.edu/Research-Resources/CTRCs/NutritionCore/Documents/food_preferences_caffeinef.pdf

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