Webquest.fr
Création de questionnaires, formulaires et sondages sur internet
UniverSel - Potassium Questionnaire
The UniverSel questionnaire is designed to assess your salt and potassium intake.
Sometimes you may hesitate in your answers. In this case, please check the box closest to your opinion.
In addition, it is mandatory to answer each question for the questionnaire to be validated.
In the week before the urine collection, did you have any of the following events?
--- Sélectionnez un élément ---
Diarrhea
Vomiting
Sweating (sports, fever, ....)
No event
Day of urine collection
--- Sélectionnez un élément ---
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Name (first letter) *
First name (first letter) *
Date of filling *
Age *
Weight (kg) *
Height (cm) *
Are you? *
A man
A woman
Do you eat vegetables? *
3 vegetables a day or more
1-2 vegetables per day
Never
Do you eat fruits or drink glasses of fruit juice? *
4 or more fruits (glasses) per day
3 fruits (glasses) per day
1-2 (glasses) of fruit per day
Never
Do you eat bananas? *
1 banana per day or more
1 banana per week
Never
Do you eat mushrooms? *
2-3 times a week
Once a week
Once a month
Never
Do you eat chocolate bars (or equivalent)? *
1 bars per week or more
1 bar per month
Never
Do you eat dried vegetables (lentils, dried beans, dried peas, split peas, chickpeas, dried beans,...) and/or potatoes? *
4 or more times a week
2-3 times a week
Once a week
Less than once a week or never
Do you eat dried fruits (apricots, dates, figs, peanuts, almonds, hazelnuts, .....)? *
4 times a week or more
2-3 times a week
Once a week
Less than once a week or never
Do you eat? *
More than others
Like the others
Less than others
Do you object to the data from this questionnaire being used for statistical analysis in an anonymous manner? *
Yes
No
Attention tous les champs obligatoires n'ont pas été complétés.
Le questionnaire n'a pas été validé.
Attention au vol de données : ne saisissez jamais de mots de passe dans un questionnaire.