Arizona Tea Questionnaire
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PLEASE DO NOT WRITE IN THIS AREA SERIAL # DIRECTIONS 3/8" PERF 1. Name: Mark Reflex ® forms by Pearson NCS MM250021-1 654321 HC05 Printed in U.S.A. 2. Today's Date: 3. Phone Number: 4. Age: years old 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 1 Month Day Year 2 OFFICE USE ONLY ) – ( Herbal tea drinker only Please print your Name, Today's Date, Phone Number, Age, and Sex in the boxes provided. Please shade bubbles like this: and not like this: ✗ ✓ 5. Sex: Male Female Yes - Go to Question 18 (Page 7) No - STOP Frequent or regular tea drinker Never drink tea 6a. Which of the following responses best describes your tea use or consumption in the past year (Include hot, iced, and herbal teas)? IF YOU CURRENTLY DO NOT DRINK TEA: 6b. Did you used to drink tea? • Use a #2 pencil • Make no stray marks • Fill in the circles completely Occasional tea drinker Part 1: Demographics USE A NO. 2 PENCIL ONLY Arizona Tea Questionnaire 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 ID NUMBER STUDY A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 STAGE
Transcript of Arizona Tea Questionnaire
PLEASE DO NOT WRITE IN THIS AREA
SERIAL #
DIRECTIONS
3/8"
PE
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1. Name:
Mark Reflex® forms by Pearson NCS MM250021-1 654321 HC05 Printed in U.S.A.
2. Today's Date:
3. Phone Number:
4. Age: years old0
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OFFICE USE ONLY) –(
Herbal tea drinker only
Please print your Name, Today's Date, PhoneNumber, Age, and Sex in the boxes provided.
Please shade bubbles like this:
and not like this: ✗✓
5. Sex: Male Female
Yes - Go to Question 18 (Page 7) No - STOP
Frequent or regular tea drinker
Never drink tea
6a. Which of the following responses best describesyour tea use or consumption in the past year(Include hot, iced, and herbal teas)?
IF YOU CURRENTLY DO NOT DRINK TEA:6b. Did you used to drink tea?
• Use a #2 pencil• Make no stray marks• Fill in the circles completely
Occasional tea drinker
Part 1: Demographics
USE A NO. 2 PENCIL ONLY
Arizona Tea Questionnaire
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3/8" PE
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7a. Do you drink HOT tea?
Page 2 - Arizona Tea
Part 2: For the following questions answer for your USUAL type of HOT tea
Yes - Continue No - Go to Question 8a (Next Page)
7b. How much of the HOT tea you drink is decaffeinated?None 25% 50% 75% All
IF YES:
7c. How do you usually drink your HOT tea?Weak Medium Strong Very Strong
7d. At what temperature do you usually drink your HOT tea?Room temperature Warm Hot Very Hot
7e. At what time of day do you usually drink your HOT tea?Throughout the day With meals only Between meals only
7f. How do you usually prepare your HOT tea?RecipeRestaurant Bottled only Don't know - Go to Next Page
7g. When making HOT tea howmuch do you use?
If RECIPE:
OR
bags percup
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7h. How long do you brew yourHOT tea?
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7i. Do you usually add anything to your tea?Yes Never - Go to Next Page
Sometimes
CitrusSpicesSugars/sweeteners
7j. What do you add to your HOT tea?Herbs or herbal teaMilk
If you add anything to your tea:
3/8"
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Page 3 - Arizona Tea
Part 3: For the following questions answer for your USUAL type of ICED tea.
8a. Do you drink ICED tea?Yes - Continue No - Go to Question 9 (Next Page)
8b. How much of the ICED tea you drink is decaffeinated?None 25% 50% 75% All
IF YES:
8c. How do you usually drink your ICED tea?Weak Medium Strong
8d. Do you usually add ice to your ICED tea before drinking?Yes Sometimes Never
8e. How much of your BLACK ICED tea is usually sun tea?None 25% 50% 75% All
Very Strong
8g. How long do you keep it refrigerated?
8h. At what time of day do you usually drink your ICED tea?Throughout the day Between meals only
8f. How much of your GREEN ICED tea is usually sun tea?
None 25% 50% 75% All
With meals only
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8i. How do you usually prepare your ICED tea?Recipe
Bottled only Restaurant Don't know - Go to Next Page
IF RECIPE:
8l. Do you usually add anything to your tea?Yes Never - Go to Next Page
Sometimes
Citrus8m. What do you add to your ICED tea?
Milk
8j. When making ICED tea how much do you use?
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8k. How long do you brew your ICED tea? OR
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If you add anything to your tea:
SpicesSugars/sweeteners
Herbs or herbal tea
tea bags or teaspoonsper 1/2 gallon pot
hoursminutes
Part 4: The next questions ask about your use of various types of tea duringthe past year.
PLEASE DO NOT MARK IN THIS AREA
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HOT Black Tea
ICED Black Tea
HOT Green Tea
ICED Green Tea
HOT Herbal Tea
ICED Herbal Tea
11. When you drink tea, how much do you usually drink? Please fill in the correct answer for each type of tea.
NoneTeacup(7 oz.)
Mug(9 oz.)
Glass(12 oz.)
LargeMug
(11 oz.)
LargeGlass
(16 oz.)
HOT Black Tea
ICED Black Tea
HOT Green Tea
ICED Green Tea
HOT Herbal Tea
ICED Herbal Tea
10. How often do you usually drink the following teas IN THE WINTER?Please fill in the correct answerfor each type of tea. Never/
rarely
Lessthan
1 cup/month
1-3cupsper
month
2-3cupsper
week
1cupper
week
4-6cupsper
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1-2cupsperday
3+cupsperday
HOT Black Tea
ICED Black Tea
HOT Green Tea
ICED Green Tea
HOT Herbal Tea
ICED Herbal Tea
9. How often do you usually drink the following teas IN THE SUMMER? Please fill in a response for each type of tea. Never/
rarely
Lessthan
1 cup/month
1-3cupsper
month
2-3cupsper
week
1cupper
week
4-6cupsper
week
1-2cupsperday
3+cupsperday
SERIAL #
3/8" PE
RF
PLEASE DO NOT MARK IN THIS AREA
SERIAL #
3/8"
PE
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12. Of the tea you drink what percentage is from BAGS, LOOSE, INSTANT andBOTTLED/CANNED? If 0%, leave the box blank.
HOT Herbal Tea ICED Herbal Tea
HOT Black Tea
ICED Green Tea
ICED Black Tea
HOT Green Tea
Page 5 - Arizona Tea
Bags%
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3/8" PE
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Page 6- Arizona Tea
Part 5: The following questions are about your LIFETIMECONSUMPTION of tea.
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13. For how many years have you been drinking tea?
14. How many years did you drink tea before you were age 25?
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16. What brand do you usually use?
17. Is the pattern you have described for the past year similarto this lifetime pattern?
Yes
No - Describe Changes:
cups permonth
years
years
THANK YOU FOR YOUR TIME. STOP HERE.
years
cups permonth
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18. How many years did you drink tea before stopping?
The following questions are for those who are currently non-tea drinkers.
19. How many years did you drinktea before you were age 25?
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20. When you were drinking tea, how many cups oftea did you usually drink per month?
21. What type of tea were you usually drinking?
22. Why did you quit?
Black Green Herbal Mix
Health problems
THANK YOU FOR YOUR TIME. STOP HERE.
Didn't like tasteOther (Specify: )
Page 7- Arizona Tea
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SERIAL #
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InterviewMethod:
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Page 8- Arizona Tea
