A simple nutrition questionnaire (e.g. as used with the NutriGenie programme or as follows ) serves as a tool of enquiry that most women should be able to complete before meeting staff at their local clinic. Answers given provide a useful starting point for identifying possible areas of dietary concern which might need to be addressed more deeply in a later one-to-one interview.

1) Are you frequently bothered by any of the following (circle those that apply) ?

    nausea      vomiting      heartburn      constipation

2) How often do you skip meals in a week ?

3) Do you try to limit the amount or kind of foods eaten , in order to control your weight ?

4) Are you currently on a special diet ?

5) What foods do you avoid for health or religious reasons ?

6) Do you have a working stove ? Do you have a working refrigerator ?

7) Do you sometimes run out of food before being able to buy more ?

8) Can you afford to eat the way you should ?

9) Which (if any) social welfare benefits are you receiving that help to provide food ?

10) Do you feel you need help in obtaining food ?

11) How much of what did you drink yesterday ?

12) How much of what foods did you eat yesterday ?

13) Was yesterday typical of your usual nutritional habit , or in what way different to usual ?

14) Do you exercise vigorously for at least a half hour several times per week ?

15) How many cigarettes do you smoke ?

16) How many alcoholic beverages do you drink ?

17) Do you take (circle any that apply)