Needs Assessment Form Purpose: To understand the participant’s physical home and work environment, as well as the social or family environment. The following questions were developed to assess needs regarding goal setting for change in eating habits within specific eating occasions based on need states. The grey highlighted questions indicate the introduction or beginning question for each topic.

Typical Weekday Schedule and Responsibilities Say something like: I would like to learn more about you and your schedule, such as who you live with, whether you work inside or outside of the home, what time you eat, who prepares the meals, who you eat with, and where you eat, because these things may affect your eating habits.

Household Composition Ask: How many adults live in your home (not counting yourself)? Number of adults _________ (include adult children > 18 yrs) Adult #1: Relationship to participant: ________________ Age: ________ Gender: F / M Adult #2: Relationship to participant: ________________ Age: ________ Gender: F / M Adult #3: Relationship to participant: ________________ Age: ________ Gender: F / M Ask: Do you have children living in your home? If yes, ask about ages and gender. Child #1: Age: _______________ Gender: F / M Child #2: Age: _______________ Gender: F / M Child #3: Age: _______________ Gender: F / M

Employment—type of work, days and hours Ask: Do you work inside or outside the home? Ask: If employed outside the home, where do you work and what do you do?

Ask: What days of the week do you work and what are your hours?

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Tailoring to Participant’s Needs

Meal Patterns—timing, location and content of meals and snacks Ask: On a typical weekday, when do you eat? (For this questionnaire, weekdays are Monday through Thursday and weekends are Friday through Sunday; note whether participant considers Friday a weekday and eats accordingly.)

Review whether the participant considered these occasions as meals or snacks. Ask: For these meals and snacks, what do you usually eat? (Ask this for each occasion, whether meal or snack.)

Eating with Others Say: Tell me whether you eat alone or with others for these meals and snacks.

Eating Location Say: I would also like to know where you eat your weekday meals and snacks. Tell me about… (Review the meals and snacks described.)

Tailoring to Participant’s Needs

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Weekends (Friday, Saturday, Sunday) Ask: Generally, how does your schedule—when, where and what you eat—differ on a typical weekend day?

Activities and Schedules Say: Tell me about any of your regular activities and how they affect your eating schedule or what you eat (activities such as bowling, book clubs, family events, volunteer work).

Say: Describe other family members' schedules (school, work, activities).

Ask: How do their schedules affect your eating schedule or what you eat?

Food Preparation Ask: Who has most of the responsibility for meal preparation? (How are the duties shared? Percentages?)

Say: Tell me how you decide what to prepare. (Probe for use of menu planning, familiar standbys, routines, etc.)

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Tailoring to Participant’s Needs

Say: Tell me how you use meal plans or menus and recipes. (Probe for information about scratch cooking and baking or using convenience products, e.g., pre-made meal solutions such as frozen stir-fry dinners in a bag, Lean Cuisine meals, canned chili, bagged lettuce, cut up fruits.)

If the participant has children, ask: Who prepares meals for children?

Ask: How many family dinners do you have each week? (Family dinners include at least one parent, caregiver, or supportive adult eating an evening meal with a child.) Ask: How does feeding children or other family members affect what you eat?

Grocery Shopping Patterns Ask: Who has most of the responsibility for grocery shopping? (How are the duties shared? Percentages?)

Ask: Where do you usually shop for groceries? How often?

Ask: How do you decide when you need to shop for groceries and what to buy? (Probe for the use of a list.)

Eating Prepared Food Away or at Home Ask: How often do you buy fast-food, order food delivered (to eat at home), eat out at a restaurant, or buy takeout food (to eat at home)? 1/month

2-3/month

1/week or more

Say: Where do you usually go when you eat out? Tell me what a typical meal out would be like.

Tailoring to Participant’s Needs

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Say: Tell me the names of restaurants or fast food places where you usually eat out.

Ask: How do you decide when to eat out? How do you decide what to order?

Usual Intake (In General) Ask about specific eating and drinking habits.

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Milk: What type do you drink, how much and how often?

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Other dairy products: How much and how often do you eat cheese, cottage cheese, ice cream, sour cream and the like? What type of these foods do you eat? (e.g., low fat or full fat)

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100 percent fruit juice: How much and how often do you drink?

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Soda pop: How much and how often do you drink? What kind? (regular or diet)

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Fruit: What types and form (fresh, canned, frozen, dried) do you eat? How many servings do you have a day?

Tailoring to Participant’s Needs

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Vegetables: What types and forms (fresh, canned, frozen) do you eat? How many servings do you have a day?

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Meats: What types (processed, such as hot dogs, sausage, bologna, salami) and/or cuts (steak, chicken breast, pork chops) do you eat? How many servings do you have a day?

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How do you prepare meat? Fried, breaded, baked, grilled, roasted, or broiled?

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Do you usually add butter, stick or tub margarine, or buttery spreads to bread, potatoes, vegetables?

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Do you ever eat meatless meals, such as beans or eggs?

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What beverages do you typically drink with meals?

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What desserts or sweets do you typically eat with meals? (describe, if necessary)

Tailoring to Participant’s Needs

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