Heritage to Health

Culinary Nutrition Program

Email

First and last name

Phone

Address

Social Determinant & Health Status

Annual Household Income Bracket

What is Your Household Size?

Have you been unemployed in the last 12 months?

Yes

No

What is your highest level of education completed?

Do you rent, own, or occupy?

Rent

Own

Occupy

Have you cut meal size/skipped meals because there was not enough money in the last 12 months?

Yes

No

Have you been able to afford to eat balanced meals in the last 12 months?

Yes

No

Have you received government food assistance (eg, food stamps, SNAP)?

Yes

No

Can you easily get to stores that sell affordable fresh vegetables and fruits?

Yes

No

In general, would you say your health is

Nutrition knowledge and label literacy

Food from my culture is healthy.

Agree

Disagree

Neutral

How many portions of fruit and vegetables do you think health experts recommend eating everyday?

I understand how to read and interpret the nutrition label.

Agree

Disagree

Neutral

Fiber can decrease the chances of gaining weight.

Agree

Disagree

Not sure

Eating bread always causes weight gain.

Agree

Disagree

Not sure

To eat healthy people need to cut out fat completely.

Agree

Disagree

Not sure

To maintain a healthy weight people should eat a high protein diet.

Agree

Disagree

Not sure

One healthy way to add flavor to food without adding extra fat or salt is to add:

Coconut milk

Herbs

Soy sauce

Not sure

Which one of these foods is classified as having a high glycemic index?

Whole grain cereals

White bread

Fruits and vegetables

Not sure

Which one of these foods is more likely to raise people’s blood cholesterol?

Eggs

Vegetable oils

Animal fat

Not sure

Which of these options do experts recommend to prevent diabetes?

Eating less refined foods

Drinking more fruit juice

Eating more processed meat

Not sure

Which of these fats should you limit intake of?

Saturated fat

Unsaturated fat

What foods and drinks do you think are typically high in added sugar?

What foods and drinks do you think are typically low in added sugar?

What foods and drinks do you think are typically high in salt?

What foods and drinks do you think are typically low in salt?

What foods and drinks do you think are typically high in fibre?

What foods and drinks do you think are typically low in fibre?

What foods do you think are a good source of protein?

Which of the following foods do experts count as starchy foods?

Which foods have polyunsaturated fat as the main type of fat present?

Olive oil

Butter

Sunflower oil

Eggs

Which foods have monounsaturated fat as the main type of fat present?

Olive oil

Butter

Sunflower oil

Eggs

Which foods have saturated fat as the main type of fat present?

Olive oil

Butter

Sunflower oil

Eggs

Which foods have cholesterol fat as the main type of fat present?

Olive oil

Butter

Sunflower oil

Eggs

Compared to minimally processed foods, processed foods are

Higher in calorie

Higher in fiber

Lower in salt

Not sure

Dietary & Health Behaviors

Do you have any food allergies or intolerances? If so, please list them.

Which of these apply to you?

Current smoker

Ex-smoker

Never smoked

How many times a day do you eat fruit?

How many times a day do you eat vegetables?

How many different kinds of vegetables do you usually eat a day?

How often do you drink regular sodas (not diet)?

I use nutrition labels to help make the healthiest choice.

True

False

I eat lower fat dairy products.

True

False

I eat lower- or reduced-fat products.

True

False

Cooking Skills & Habits

Who usually does the cooking at home?

Me

My partner

Family members

We do not cook at home

How often do you plan your meals before you shop for groceries?

How many days a week do you cook dinner (your main meal) at home?

I know how to make substitutions for items in a recipe.

Agree

Disagree

Neutral

How is your food usually prepared? (Tick all that applies)

Physical activity

How often do you dedicate 30 minutes per day for physical activity, such as walking, biking, or swimming?

Everyday

1-2 times a week

3-4 times a week

5-6 times a week

In a typical week, how much time do you spend in total on moderate and vigorous physical activities where your heartbeat rises and you breathe faster?

Less than ½ an hour (less than 30 minutes)

½ an hour - 1 ½ hours (30-90 minutes)

1 ½ - 2 ½ hours (90-150 minutes)

2 ½ - 5 hours (150-300 minutes)

More than 5 hours (more than 300 minutes)

How much of the time that you spend on physical activities in a typical week, which you indicated above, do you spend in total on vigorous physical activities -- activities that get your heart racing, make you sweat, and make speaking difficult?

Less than ½ an hour (less than 30 minutes)

½ an hour - 1 hour (30-60 minutes)

1 - 1 ½ (60-90 minutes)

1 ½ - 2 ½ (90-150 minutes)

More than 2 ½ hours (more than 150 minutes)

Self-efficacy

I am confident that I can be healthy while eating cultural foods that I'm accustomed to.

How confident do you feel about preparing and cooking new foods and recipes?

How confident do you feel about tasting foods that you have not eaten before?

How confident are you reading nutrition labels?

How confident are you that you can eat only a very small amount of fried foods like fried chicken, French fries, potato chips, or other fried foods each week?

How confident are you that you can reduce or omit fats (butter, fatty meats or oils) in cooking vegetables, beans, or frijoles?

How confident are you that you can reduce the amount of butter and other fats or oils that you eat each day?

How confident are you that you can select lower calorie foods at a fast food restaurant?

How confident are you that you can reduce or omit drinking sugary drinks like Kool-Aid, colas, sugared teas and coffee, or other sugared soft drinks?

How confident are you that you can reduce the amount of time you sit and watch TV?

How confident are you that you can increase the number of fruits and vegetables you eat daily?

How confident are you that you can increase time spent in physical activity while at home, given your current family responsibilities?

How confident are you that you can substitute lower calorie foods – like fruits, vegetables, or yogurt – for high calorie snacks – like cakes, pies, or ice cream?