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| 1. Can you manage eating without any help? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 2. Can you prepare meals for yourself without help? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 3. Can you shop for food and other things you need without help? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 4. Can you pick up the food? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 5. Can you grasp utensils and cups? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 6. Can you get food on utensils? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 7. Can you bring food, utensils, cups to mouth? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 8. Can you chew, swallow food and liquids? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 9. Can you clean your mouth and hands as necessary following a meal? | (A) Independent | (B) Verbal assistance | (C) Some human help | (D) Dependent |
| 10. Is there any weight loss during the last 3 months? | (A) No weight loss | (B) Does not know | (C) Between 1 and 3 kg | (D) >3 kg |
| 11. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? | (A) Severe loss of appetite | (B) Moderate loss of appetite | (C) No loss | |
| 12. How many full meals do you eat daily? | (A) 1meal | (B) 2 meals | (C)3 meals | (D) >3 meals |
| 13. How many snacks do you eat daily? | (A) 1 meal | (B) 2 meals | (C)3 meals | (D) >3 meals |
| 14. How much vegetables being consumed per day? | (A) One | (B) Two | (C) Three | (D) >three |
| 15. How much fruits being consumed per day? | (A) One | (B) Two | (C) Three | (D) >three |
| 16. How much water is consumed per day? | (A) <3 cups | (B) 5 cups | (C) 7 cups | (D) >7 cups |
| 17. How much juice is consumed per day? | (A) None | (B) One cup | (C) 2 cups | (D) >2 cups |
| 18. How much milk is consumed per day? | (A) None | (B) One cup | (C) 2 cups | (D) >2 cups |
| 19. How much tea and coffee consumed per day? | (A) None | (B) One cup | (C) 2 cups | (D) >2 cups |
| 20. How much white or brown bread consumed per day? | (A) None | (B) <loaf | (C) 1-2 loaf | (D) >2 loaf |
| 21. How much rice or spaghetti consumed per day? | (A) None | (B) <cup | (C) 1-2 cup | (D) >2 cups |
| 22. How many serving of dairy products did you eat daily? | (A) None | (B) 1–2 serving | (C) 3–4 serving | (D) >4 servings |
| 23. How much meat or chicken or fish consumed per day? | (A) None | (B) <1 piece | (C) 1–2 piece | (D) >2 serving |
| 24. How often do you eat eggs? | (A) None | (B) One egg | (C) 2–3 eggs | (D) >3 eggs |
| 25. How often do you eat nuts like pistachios, nuts, cashews, hazelnuts, etc.? | (A) None | (B) once a day | (C) Twice a day | (D) >2 a day |
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