Neurological disorder Obesity Seizures/Stroke Thyroid problem Tumors/Cancer Ulcers Other Have you been hospitalized within the last 5 years?
¾ Cause
Do you have a history of more than 1 miscarriage?
o Yes
o No
If you are selected to participate in this study are you willing to sign an informed consent understanding we have access to medical information on you?
o Yes
o No
Month Day Year
How would you describe your race or ethnic background?
o White
o Black or African American
o American Indian or Alaska Native o Hispanic or Latino
o Asian
o Native Hawaiian or Other Pacific Islander
o Other _________________________________________________
What is the highest level of school or training that you have completed? [Circle only one response]
Grade school 01 02 03 04 05 06 07 08
High school 09 10 11 12
Technical school or college 13 14 15 16 Graduate or professional 17 18 19 20+ Don’t know X Marital status? o Single/never married o Married o Separated o Divorced o Widowed
Are you a full-time or part-time student? Are you employed?
o Full time o Yes
o Part time o No
Contact Information
Name of person and phone number to call in case of an emergency if you are invited to participate in this study:
______________________________________________________________________________
If we need to contact you, and can not reach you where/with who can a message be left? ______________________________________________________________________________
How did you hear about our study? _______________________________________________ Name
M / F
Last First Middle
Street Apt. #
Address
City Zip code
Phone
Day Evening Cell
APPENDIX B INTERVENTION DIET
Diet – B12 Intervention Study
DAY 1 DAY 2
Breakfast Breakfast
• Juice (apple or cranberry) • Scrambled egg
• Bread • Toast with jelly
• Coffee/tea
• Juice (apple or cranberry)
Snack Snack
• Graham crackers • Graham crackers
• Peanut butter • Peanut butter
• Apple • Apple
• Coffee/tea • Beverage*
Lunch Lunch
• Grilled cheese sandwich • Pita sandwich with hummus and veggies
• Fruit cocktail • Corn chips
• Pudding • Pineapple
• Beverage* • Beverage*
Dinner Dinner
• Bean burrito • Cheese tortellini with spaghetti sauce
• Brown rice • Green beans
• Salad with dressing • Mandarin oranges
• Pears • Jello
• Beverage* • Beverage*
Snack Snack
• Sherbet • Pudding
• Pound cake • Shortbread cookies
• Beverage* • Beverage*
*Beverage may be Crystal Light, non-caffeinated soda, Gatorade, Hawaiian Punch (selection to be made with the help of research staff)
Non-caffeinated, non-caloric beverages (Crystal Light, diet soda, water) available throughout the day as desired
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