DIET HISTORY QUESTIONNAIRE III(DHQ III)

The DHQ is a freely available questionnaire created by the national cancer institute for cancer patients to track down their diet. We adapted the very long DHQ III for use here to help you survey your eating habits and hopefully make some healthy changes.

Please keep in mind that the questionnaire below is only a small sample of the actual questionnaire.

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BEVERAGES

What beverages did you drink?

Below is a list of beverages that you could have consumed over the past month.  For each item that applies ask yourself the following 2 questions:

1.Over the past month, how often did you drink _?

 1 time in the past month

2-3 times in the past month

 1-2 times per week

3-4 times per week

5-6 times per week

1 time per day

2-3 times per day

4-5 times per day

6 or more times per day

2. Each time you drank __, how much did you usually drink?

Less than 3⁄4 cup (6 ounces)

3⁄4 to 11⁄2 cups (6 to 12 ounces)

More than 11⁄2 cups (12 ounces)

LIST:

• Tomato juice or vegetable juice
• Orange juice or grapefruit juice

 – Grape juice

 – Other 100% fruit juices or 100% fruit juice mixtures (such as apple, pineapple, or others)

 – Fruit or vegetable smoothies

 – Other fruit drinks, regular or diet (such as Hi-C, fruit punch, lemonade, or cranberry cocktail)

• Milk as a beverage (NOT in coffee, tea, or cereal; including soy, rice, almond, and
• Coconut milk; NOT including chocolate milk, hot chocolate, and milkshake)
• Chocolate milk or hot chocolate
• Milkshakes
• Meal replacement or high-protein beverages (such as Ensure, Boost, Muscle Milk,
• Slimfast, Instant Breakfast, or others; NOT including any added protein powder)
• Soda or pop
• Sports drinks (such as Gatorade, Powerade, or Propel)
• Energy drinks (such as Red Bull or Jolt)
• Water (including tap, bottled, and carbonated water; NOT including vitamin water)
• Vitamin water (such as SoBe, Propel Zero, or Glaceau Water)
• Beer
• Wine or wine cooler
• Liquor or mixed drinks
• Coffee, caffeinated or decaffeinated (including brewed coffee, instant coffee, or espresso shots; NOT including espresso drinks such as latte, mocha, etc.). Espresso drink mixtures, caffeinated or decaffeinated (including latte, mocha, cappuccino, etc.)

• COLD or ICED tea, caffeinated or decaffeinated (NOT including herbal or green tea)
• HOT tea, caffeinated or decaffeinated (NOT including herbal or green tea) Green tea

• Herbal or fruit tea (including hibiscus, chamomile, licorice, sassafras, etc.)

FRUITS

What fruits have you eaten?

Below is a list of fruits that you could have consumed over the past month.  For each item that applies ask yourself the following 2 questions:

1. Over the past month, how often did you eat __?

1 time in the past month

 2-3 times in the past month

1 time per week

2 times per week

3-4 times per week

5-6 times per week

1 time per day

2 or more times per day

2. Each time you ate _, how much did you usually eat?

 Less than 1 _   

 1 _

 More than 1 _

For canned fruits and melons

Less than 1⁄4 cup or less than 1 medium slice

1⁄4 to 3⁄4 cup or 1 medium slice

More than 3⁄4 cup or more than 1 medium slice

LIST:

• Applesauce
• Apples
• Bananas
• Pineapple (fresh, canned, or frozen)
• Pears (fresh, canned, or frozen)
• Peaches, nectarines, or plums
• Dried fruit (such as prunes or raisins)
• Grapes
• Cantaloupe
• Melons, other than cantaloupe (such as watermelon or honeydew)
• Strawberries
• Blueberries
• Oranges, tangerines, or clementines
• Grapefruit       
• Avocado or guacamole
• Other kinds of fruit (not listed above)

VEGETABLES, POTATOES, AND BEANS

What vegetables, potatoes, and beans did you eat?

Below is a list of vegetables, potatoes and beans that you could have consumed over the past month.  For each item that applies ask yourself the following 2 questions:

1- Over the past month, how often did you eat ________

1 time in the past month

2-3 times in the past month

1 time per week

2 times per week

3-4 times per week

5-6 times per week

1 time per day

2 or more times per day

2- Each time you ate _, how much did you usually eat?

Less than 1⁄4 cup

1⁄4 to 3⁄4 cup

More than 3⁄4 cup

LIST:

• COOKED greens (such as spinach, turnip, collard, mustard, chard, or kale)
• RAW greens (such as spinach, turnip, collard, chard, kale, watercress, seaweed,

mustard greens, beet greens, or dandelion greens)

 – Coleslaw

• Sauerkraut or cabbage (other than coleslaw)
• COOKED carrots (including frozen, fresh, or canned)
• RAW carrots
• String beans or green beans (fresh, canned, or frozen)
• Peas (fresh, canned, or frozen)
• Corn (fresh, canned, or frozen)
• Broccoli (fresh or frozen)
• Cauliflower or Brussels sprouts (fresh or frozen)
• Sweet peppers (green, red, or yellow)
• Onions
• Garlic
• Mixed vegetables
• Lettuce salads (with or without other vegetables)
• Salad dressing on salads (including low-fat or fat-free)
• Mayonnaise on salads (including low-fat, diet, or light)
• Fresh tomatoes (including those in salads)
• Salsa
• Catsup or ketchup
• Sweet potatoes or yams
•  French fries, home fries, hash browned potatoes, or Tater Tots
• Potato salad
• Baked, boiled, or mashed potatoes
• Cooked dried or canned beans (such as baked beans, pintos, kidney, black-eyed peas, lima, lentils, soybeans, or refried beans; NOT including bean soups or chili)
• Other kinds of vegetables (not listed above)

RICE, PASTA, PIZZA:

What rice, pasta, and pizza have you eaten?

Below is a list pasta, rice and pizza that you could have consumed over the past month.  For each item that applies ask yourself the following 3 questions:

1. Over the past month, how often did you eat __ ?

1 time in the past month

2-3 times in the past month

1 time per week

2 times per week

3-4 times per week

5-6 times per week

1 time per day

2 or more times per day

2. Each time you ate _, how much did you usually eat?

Less than 1⁄2 cup

1⁄2 to 1 cup

More than 1 cup

3. How often was the _ you ate whole grain?

Almost never or never

About 1⁄4 of the time

About 1⁄2 of the time

About 3⁄4 of the time

Almost always or always

LIST:

• Rice or other cooked grains (such as bulgur, cracked wheat, or millet; NOT including

sushi)

• Sushi

Each time you ate sushi, how much did you usually eat?

Fewer than 5 pieces or less than 1 cup

5 to 8 pieces or 1 to 2 cups

More than 8 pieces or more than 2 cups

• Lasagna, stuffed shells, stuffed manicotti, ravioli, or tortellini (including gluten-free; NOTincluding spaghetti or other pasta)
• Macaroni and cheese (including gluten-free)
• Pasta salad or macaroni salad (including gluten-free)
• Pasta, spaghetti, or other noodles (other than those listed above; including gluten-free)
• Pizza (including gluten-free)

CEREALS, PANCAKES AND BREADS

What cereal, pancakes, and breads have you eaten?

Below is a list of cereals, pancakes and breads that you could have consumed over the past month.  For each item that applies ask yourself the following 2 questions:

1. Over the past month, how often did you eat __ ?

1 time in the past month

2-3 times in the past month

1 time per week

2 times per week

3-4 times per week

5-6 times per week

1 time per day

2 or more times per day

2. Each time you ate ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_, how much did you usually eat?

Less than 1 medium piece or less than 1 cup

1 to 3 medium pieces or 1 to 2 cups

More than 3 medium pieces or more than 2 cups

LIST:

• Oatmeal, grits, or other cooked cereals
• Cold cereal (including gluten-free)
• Pancakes, waffles, or French toast (including gluten-free)
• Bagels or English muffins (including gluten-free)
• Breads or rolls AS PART OF SANDWICHES (including gluten-free)
• Breads or dinner rolls NOT AS PART OF SANDWICHES (including gluten-free)
• Cornbread or corn muffins
• Biscuits
• Jam, jelly, or honey (on bagels, muffins, breads, rolls, crackers, etc.)
• Peanut butter or other nut butter
• Hummus

Source: https://epi.grants.cancer.gov/dhq3/