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HEALTH & DIET SURVEY
INTRODUCTION: We are studying attitudes about health and healthy eating. Your feedback will be
anonymous
and will help to shape the educational materials and healthy products that are made available to Americans. Please begin the survey now.
Please indicate whether you are concerned about any of these health problems. . . .
(check all that apply)
Concerned for Myself
I've Been Diagnosed With This Condition
Concerned for a Family Member
Diabetes
Heart attack
Heart disease
High blood pressure
High cholesterol
Overweight
Peripheral Artery Disease
Stroke
Have any of your close relatives suffered from the health problems mentioned above? If yes, please indicate which relatives.
(check all that apply)
None
Mother
Father
Brother
Sister
Grandparent
Son/Daughter
Don't Know
Do you wish you knew more about any of these health topics? (check all that apply)
exercise
healthy recipes
cholesterol control
oral care
proper diet
blood pressure control
none
Other
Now for some questions about eating habits....
What brand(s) of
Probiotic Yogurts
have you
heard of
, have you
bought in the last 3 months
, and which ones do you
plan to buy next
? (Please complete all 3 columns, marking any that apply)
Heard Of
Bought in Past 3 Months
Plan to Buy Next
Breyer’s Light
Dannon Activia
LaYogurt
Stonyfield Farms
Yoplait Yo-Plus
Store brand probiotic yogurt
Other
None/Don’t know
Which
soups/broths
have you
bought in the last 6 months
, which ones do you
plan to buy next
, and which ones do you
buy most often
? (Please complete all 3 columns, marking any that apply)
Bought in Past 6 Months
Plan to Buy Next
Buy Most Often
CANNED SOUPS
Don’t Use Canned Soups
Amy’s
Campbell’s Chunky
Campbell’s Condensed
Campbell's Healthy Request
Campbell’s Lower Sodium
Campbell’s Select Harvest
College Inn
Healthy Choice
Bought in Past 6 Months
Plan to Buy Next
Buy Most Often
Healthy Valley
Progresso
Swanson
V8 soup
Other canned soup
DRY SOUPS
Don’t Use Dry Soups
Campbell’s
Herb-Ox
Knorr
Bought in Past 6 Months
Plan to Buy Next
Buy Most Often
Lipton
Wyler’s
Other dry soup
OTHER SOUPS
Ramen noodles
Homemade soups
Other
Do you take an aspirin a day to prevent a heart attack?
Yes
No
Which brands of
aspirin
have you
heard of
, have you
bought in the past 3 months
, and which ones do you
plan to buy next
? (Please complete all 3 columns, marking any that apply)
Heard Of
Bought in Past 3 Months
Plan to Buy Next
Bayer
Ecotrin
Excedrin
St. Joseph's
Store Brand
None/Don't Know
Other
Are you currently taking prescription medications to control any of these? (check all that apply)
blood thinning
diabetes
heart rhythm
high blood pressure
high cholesterol
don't know/not sure
Other
Please contact
survey@adialogue.com
if you have any questions regarding this survey.
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