NUTRITIONAL STATUS SURVEY
(By P. M. Veroy RN, MAN)
Personal Data:
Name: (Optional)_____________________________________
Ag...
Bread (Pan de amerikano, pan de leche, monay, pan de sal)
2 slice or 2 pc.
(average of 6x5x4 cm) n
size
Wheat, oats, noodl...
3. Do you drink alcohol? _____No ____ Yes
4. If YES, what type of alcohol? _____ (beer any kind, gin, rum, whisky, brandy)...
4. How often do you eat HIGH FAT MEATS such as marbled or untrimmed beef, beef, pork, hamburger meat,
poultry with skin, s...
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Nutrional status survey

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A survey questionnaire use to determine nutritional status of individual

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Nutrional status survey

  1. 1. NUTRITIONAL STATUS SURVEY (By P. M. Veroy RN, MAN) Personal Data: Name: (Optional)_____________________________________ Age________ Gender_________ Height_________ Weight (Kg) ________ Religion: ( ) R. Catholic ( ) SDA ( ) Islam; Others please specify:_____________________ Directions: 1. Be sure to fill out the questionnaire as accurately as possible and avoid underestimating your food intake. 2. Your food choices should cover the past three (3) months until the present to show what you eat in your regular meals everyday. 3. Mark check (/) the options that indicate serving per day with each corresponding food classification. Part A: Daily Food Consumption Survey: Food Groups Servings Per Day Vegetables Measure 4-6 2-3 1 I - A Chinese cabbage, alugbati leaves, ampalaya fruit/ leaves, bamboo shoot, banana heart, cabbage, cauliflower, celery, chayote fruit/leaves, cucumber, eggplant, gabi leaves, kangkong, lettuce, malunggay leaves, mushroom, okra, petsay, radish, saluyot, squash, string beans, tomato, upo, sitsaro. Seaweed. 1 cup, raw ½ cup, cooked 2 cups, raw 1 cup, cooked I – B carrot, coconut shoot (ubod), kamansi, langka hilaw, patani, mungbean sprout (toge), singkamas, cowpea pods, stringbeans pod. ½ cup, raw ½ cup, cooked Fruits Measure 4-6 2-3 1 Banana (any kind), mango, pineapple, papaya, watermelon, jackfruit, 1 whole fruit (for very large or small chopped) 1 cup Calamansi, orange, suha, pineapple, mango In Fruit juice ¼ cup Fresh buko juice 1/3 cup Beans and Legumes Measure 4-6 2-3 1 Baguio beans, black beans, garbanzo beans, peas 1 cup cooked Nuts and Seeds Peanut, cashew nut ¼ cup Rice, Grains, Cereals, Breads & Pastas Measure 4-6 2-3 1 Rice, cooked ½ cup, packed
  2. 2. Bread (Pan de amerikano, pan de leche, monay, pan de sal) 2 slice or 2 pc. (average of 6x5x4 cm) n size Wheat, oats, noodles, spaghetti, macaroni I cup Meats and Fish Measure 4-6 2-3 1 Lean meat of beef, pork 1 slice matchbox size Chicken (hita, laman, pitso) 1 small leg, ¼ breast (6 cm long), laman, matchbox size Food Groups Servings Per Day Internal Organs / Variety of Meat - Measure 4-6 2-3 1 Blood (Dugo) – pork, beef, chicken gizzard (balun-balunan chicken); heart, liver, lungs, spleen, small intestines, uterus (pork, Beef) ¾ cup Fish – bangus, matambaka, bariles, tune, lapu-lapu, hito, galunggong, (large and medium size fish) 1 slice (7x3x2 cm) for big fish 1 serve average of ( 18- 22x4-5x1/2-1 cm) for medium fish - small size; sapsap, tilapia, tamban, dilis ¼ cup Other Seafoods Measure 4-6 2-3 1 Shrimps (alamang) 1 ¼ tbsp. Crabs (alimango) 1 tbsp. Lobster 2 tbsp. Sea shells (kuhol, susong pilipit, taho, talaba) 2-3 cups with shell or 1 cup shelled Dairy and Eggs Measure 4-6 2-3 1 Chicken egg / salted duck’s egg 1 pc Quial’s egg 9 pieces Cheddar cheese 1 slice ( 6x3x2cm) Cheese filled 1 slice (6x3x2 ½ cm) Fresh milk (cow/goat), powdered filled milk 1 cup Butter, margarine, mayonnaise, cream, gravy, refined sugar, oil 1 tbsp or sparingly Part B : Daily Lifestyle Survey Direction: Mark check (/) your choice of answer on the underlined space before the option. Tobacco Use: 1. What best describes your use of cigarettes, pipes, and cigars? ____ Never smoked ____ Former smoker ____ Smoker 2. How many sticks or pack(s) consume per day? _______________________________. Alcohol:
  3. 3. 3. Do you drink alcohol? _____No ____ Yes 4. If YES, what type of alcohol? _____ (beer any kind, gin, rum, whisky, brandy) _____ (tuba, lambanog, grape wine, sioktong) 5. How many glasses of alcohol do you drink per day? _____ 5 glasses or more, _____ 3-5 glasses, _____ 1-3 glasses, _____on occasion only Exercise: 6. Do you exercise regularly? ____No ____Yes. If YES; how many times a week? ____everyday ____ 2-3 times, ___1-2 times ____once a week 7. Duration per exercise; ____1 hour or more, ___45mins.-1 hour, ____ 30-45 minutes, ____ 15-30 minutes 8. Type of exercise: ____Jogging, _____aerobic work-out, _____biking, ____swimming, ____weight lifting, others please specify:______________________________________ Water Intake: 9. How much glasses of plain water do you consume daily? ____10-12, ____ 8-10, ____ 6-8, _____ 5 or less Waste Elimination: 10. How often do your bowels eliminate? ____twice daily, ____once daily, ____3-4 times a week, ____once or twice a week only Sleeping Habit: 11. How many hours you usually sleep a day? ____8-10, ____6-8, ____4-6, ____less than 4 hours. 12. What type of sleeping pattern? ____ Continuous at night time, ____ With 3 or more wakes in between sleep at night time, ____irregular frequency at any time of the day, Nutritional Supplement: 13. Do you take nutritional supplement? ____ No, ____ Yes. If YES, which type? ____ vitamins/minerals, ____ amino acids, ____ herbs. 14. How often do you take it? ____ 2 times or more per day, ____ once daily, _____ every other day, ____ 2-3 times a week. Part C: Food Eating Habits Survey: Direction: Mark check (/) your choice of answer on the underlined space before the option. 1. How many times a week do you eat breakfast, lunch, or dinner in a RESTAURANT or FAST FOOD PLACE? (Include all food prepared away from home, such as take-out food and home delivered food and ready-to- eat or deli food to take home. Do not include brown bag meals prepared at home.) ___ Never eat out, ___ 1-3 times per week, ___ 4-6 times per week, ___ 7 or more times Hunger: 2. How hungry do you usually feel BEFORE you eat meals or snacks? MEALS SNACKS ___Do not eat meals ___Do not eat snacks ___Not at all hungry ___Not at all hungry ___A little hungry ___A little hungry ___Neither hungry or full ___Neither hungry or full ___Moderately hungry ___Moderately hungry ___As hungry as I have ever felt ___As hungry as I have ever felt 3. How full do you usually feel AFTER you eat meals or snacks? MEALS SNACKS ___Do not eat meals ___Do not eat snacks ___Not at all full ___Not at all full ___A little full ___A little full ___Neither hungry or full ___Neither hungry or full ___Moderately full ___Moderately full ___As full as I have ever felt ___As full as I have ever felt Food Frequency:
  4. 4. 4. How often do you eat HIGH FAT MEATS such as marbled or untrimmed beef, beef, pork, hamburger meat, poultry with skin, sausage, hotdogs, bologna, longaniza, chorizo, tocino and salami? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 5. How often do you eat FRIED FOODS such as French fries, fried meat, fried poultry, fried fish, potato or corn chips, fried vegetables, or fried cheese? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 6. How often do you use BUTTER or STICK MARGARINE with your food? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 7. How often do you eat HIGH-FAT BAKED FOODS such as biscuits, cornbread, croissants, waffles, or pancakes? (Sweet baked muffins and cookies, not included) ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 8. How often do you eat HIGH-FAT CONVENIENCE FOODS such as regular frozen dinners, entrees, or frozen pizza? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 9. How often do you eat HIGH SALT SNACKS, such as popcorn, high-fat crackers, potato chips, salted dried peas, peanuts, corn, and other snack mixes? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 10. How often do you eat HIGH-FAT, HIGH SUGARED FOODS such as ice cream, puddings, cakes, muffins, cookies, pies, doughnuts, or chocolate candy? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never 11. How often do you eat HIGH-SUGAR FOODS that are low-fat or fat-free such as desserts, cookies, frozen yugort, regular drinks, and hard candy? ____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never *** Pmv-12-27-06

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