Vegetarian Life Survey

1.  What is your gender?

     ____ Male
     ____ Female


2.  What is your age?

     ____ Under 21
     ____ 21 to 30
     ____ 30 to 39
     ____ 40 to 49
     ____ 50 to 59
     ____ 60 and Over


3.  What is your marital status?

     ____ Married
     ____ Single
     ____ Partnered


 4.  If you are partnered, how would you describe your partner?

     ____ Vegetarian
     ____ Supportive but not vegetarian
     ____ Not supportive and anti-vegetarian


5.  How many children are there in your household?

     ____ None
     ____ 1
     ____ 2
     ____ 3
     ____ 4
     ____ 5
     ____ 6 or more


6.  How many pets are there in your household?

     ____ None
     ____ 1
     ____ 2
     ____ 3
     ____ 4
     ____ 5
     ____ 6 or more


7.  If you have pets what types of pets do you have?

_________________________________________________________________


8.  How many times a week do you exercise?

     ____ None
     ____ 1
     ____ 2
     ____ 3
     ____ 4
     ____ 5
     ____ 6 or more


7.  If you do exercise, what type(s) of exercise do you get?

_________________________________________________________________



8.  Please check the one statement which applies to you.


     ____ I am cutting down on red meat

     ____ I eat only chicken and fish

     ____ I eat no meat or chicken, only fish

     ____ I occasionally eat fish but eat no meat or chicken

     ____ I do not eat any meat but I do eat eggs and dairy

     ____ I do not eat any animal products  at all (I am vegan)

     ____ Other (please specify) __________________________________


9.  I am vegetarian (or making changes in that direction)  because:
            (check all that apply)


     ____ Health

     ____ Environment

     ____ Compassion for animals

     ____ Religion

     ____ World hunger

     ____ Other (please specify) __________________________________



10.  What percentage of your diet is from grain, vegetables, and fruit?

     ____ Under 25 %

     ____ 25 to 50%

     ____ 50 to 75%

     ____ 75  to 100%



11.  What do you enjoy doing in your leisure time?

_______________________________________________________________________

_______________________________________________________________________



12.  If VSSJ organized more lectures or discussion groups, what topics
or speakers would be of interest to you?

_______________________________________________________________________

_______________________________________________________________________



13.  What other activities would you like VSSJ to make available?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________



14.  Any other comments?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________



Name __________________________________________________________________
(optional)



Phone     Home (       ) _____________ Work  (       ) ______________
(optional)