National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX N
ADULT FOOD BOOK

This page has been left blank for double-sided copying.

Daily List for Household ― Day 0
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 1
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 2
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 3
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 4
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 5
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 6
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 7
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

→
→

―

√

$

$
.

.

√

Office Use

.

_________________

______/_____

_______:_______